Basic Information
| Provider Information | |||||||||
| NPI: | 1902976236 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EL ROSE MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24 WEST EL ROSE AVE | ||||||||
| Address2: | |||||||||
| City: | PETALUMA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7077639891 | ||||||||
| FaxNumber: | 7077639896 | ||||||||
| Practice Location | |||||||||
| Address1: | 24 WEST EL ROSE AVE | ||||||||
| Address2: | |||||||||
| City: | PETALUMA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7077639891 | ||||||||
| FaxNumber: | 7077639896 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 07/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | SISLER | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7077639491 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | C26495 | 01 | STATE LICENSE # | OTHER | CP6140 | 01 | RAILROAD MEDICARE | OTHER | ZZZ75987Z | 01 | MEDI CAL | OTHER | AROSE0543 | 01 | BLUE CROSS BLUE SHIELD | OTHER | C17753 | 01 | STATE LICENSE # | OTHER | G21106 | 01 | STATE LICENSE # | OTHER | ZZZ75987Z | 01 | MEDI CAL GRP # | OTHER |