Basic Information
| Provider Information | |||||||||
| NPI: | 1831231117 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SIERRA NEVADA PATHOLOGY MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | BOX 805 | ||||||||
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| City: | NEVADA CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302713232 | ||||||||
| FaxNumber: | 5302713239 | ||||||||
| Practice Location | |||||||||
| Address1: | 155 GLASSON WAY | ||||||||
| Address2: | |||||||||
| City: | GRASS VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302746000 | ||||||||
| FaxNumber: | 5302746054 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2007 | ||||||||
| LastUpdateDate: | 11/18/2008 | ||||||||
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| AuthorizedOfficialLastName: | CUNHA | ||||||||
| AuthorizedOfficialFirstName: | ANTHONY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5302713232 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246R00000X | G30573 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Technician, Pathology |
ID Information
| ID | Type | State | Issuer | Description | 00G305730 | 05 | CA | MEDICAID |