Basic Information
| Provider Information | |||||||||
| NPI: | 1770728677 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SIERRA MOUNTAIN MEDICAL GROUP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | N/A | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10978 DONNER PASS RD | ||||||||
| Address2: | |||||||||
| City: | TRUCKEE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961610433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305821212 | ||||||||
| FaxNumber: | 5305874278 | ||||||||
| Practice Location | |||||||||
| Address1: | 10978 DONNER PASS RD | ||||||||
| Address2: | |||||||||
| City: | TRUCKEE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961610433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305821212 | ||||||||
| FaxNumber: | 5305874278 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2008 | ||||||||
| LastUpdateDate: | 12/05/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LOMBARD | ||||||||
| AuthorizedOfficialFirstName: | J | ||||||||
| AuthorizedOfficialMiddleName: | TIMOTHY | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 5305821212 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | C386870 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | C386870 | 01 | MEDICAL LICENSE NUMBER | OTHER | AL9100190 | 01 | DEA NUMBER | OTHER |