Basic Information
| Provider Information | |||||||||
| NPI: | 1811242563 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUTTER WEST BAY MEDICAL FOUNDATION | ||||||||
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| OtherOrganizationName: | ENDOSCOPY CENTER OF SANTA ROSA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2015 STEINER ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941152627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4156004280 | ||||||||
| FaxNumber: | 4156002128 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 SONOMA AVE | ||||||||
| Address2: | STE 2 | ||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954056664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075712192 | ||||||||
| FaxNumber: | 7075712194 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2012 | ||||||||
| LastUpdateDate: | 08/01/2012 | ||||||||
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| AuthorizedOfficialLastName: | COHILL | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4156007771 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SUTTER WEST BAY MEDICAL FOUNDATION | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.