Basic Information
| Provider Information | |||||||||
| NPI: | 1710110754 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH COAST FACULTY MEDICAL GROUP INC | ||||||||
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| OtherOrganizationName: | SUTTER MEDICAL GROUP OF THE REDWOODS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3883 AIRWAY DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954031670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075218809 | ||||||||
| FaxNumber: | 7075218835 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 PETALUMA AVE | ||||||||
| Address2: | |||||||||
| City: | SEBASTOPOL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954724224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078298426 | ||||||||
| FaxNumber: | 7078296675 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2009 | ||||||||
| LastUpdateDate: | 10/16/2009 | ||||||||
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| AuthorizedOfficialLastName: | LEVENBERG | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7075218879 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.