Basic Information
| Provider Information | |||||||||
| NPI: | 1881068443 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FMCPS SANTA ROSA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3820 W HAPPY VALLEY RD | ||||||||
| Address2: | SUITE 141-120 | ||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853103289 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8445408736 | ||||||||
| FaxNumber: | 6027988267 | ||||||||
| Practice Location | |||||||||
| Address1: | 435 DOYLE PARK DR | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954054515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075279510 | ||||||||
| FaxNumber: | 6027988267 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2015 | ||||||||
| LastUpdateDate: | 11/19/2015 | ||||||||
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| AuthorizedOfficialLastName: | YOUNG | ||||||||
| AuthorizedOfficialFirstName: | PAMELA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CORPORATE VP | ||||||||
| AuthorizedOfficialTelephone: | 4806397185 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
No ID Information.