Basic Information
| Provider Information | |||||||||
| NPI: | 1760833834 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUTTER BAY MEDICAL FOUNDATION | ||||||||
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| OtherOrganizationName: | SUTTER PACIFIC MEDICAL FOUNDATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2350 W EL CAMINO REAL | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | MOUNTAIN VIEW | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940406201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6506965270 | ||||||||
| FaxNumber: | 6506965279 | ||||||||
| Practice Location | |||||||||
| Address1: | 750 LAS GALLINAS AVE STE 210 | ||||||||
| Address2: | |||||||||
| City: | SAN RAFAEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949033432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154797244 | ||||||||
| FaxNumber: | 4154790917 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2016 | ||||||||
| LastUpdateDate: | 06/29/2016 | ||||||||
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| AuthorizedOfficialLastName: | GATES | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5104507357 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 363LP0200X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.