Basic Information
| Provider Information | |||||||||
| NPI: | 1831180439 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SONORA COMMUNITY HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SIERRA INTERNAL MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14542 LOLLY LN | ||||||||
| Address2: | |||||||||
| City: | SONORA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953709226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095363925 | ||||||||
| FaxNumber: | 2095337696 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 GREENLEY RD | ||||||||
| Address2: | STE 922 | ||||||||
| City: | SONORA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953705287 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095363738 | ||||||||
| FaxNumber: | 2095337696 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2005 | ||||||||
| LastUpdateDate: | 03/29/2013 | ||||||||
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| AuthorizedOfficialLastName: | JAHN | ||||||||
| AuthorizedOfficialFirstName: | ANDREW | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT FOR FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 2095365011 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SONORA COMMUNITY HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | ZZZ98386Z | 01 | CA | BLUE CROSS/BLUE SHIELD | OTHER |