Basic Information
| Provider Information | |||||||||
| NPI: | 1922115575 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SACRAMENTO KNEE & SPORTS MEDICINE MEDICAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2801 K ST STE 310 | ||||||||
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| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958165119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164546677 | ||||||||
| FaxNumber: | 9167338741 | ||||||||
| Practice Location | |||||||||
| Address1: | 2801 K ST STE 310 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164546677 | ||||||||
| FaxNumber: | 9167338741 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2006 | ||||||||
| LastUpdateDate: | 08/21/2018 | ||||||||
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| AuthorizedOfficialLastName: | RODRIGUEZ | ||||||||
| AuthorizedOfficialFirstName: | EVELYN | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | FINANCIAL ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9164546677 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0004X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery | 207XX0005X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | ZZZ00355Z | 01 | CA | BLUE SHIELD OF CALIF | OTHER | 170865900 | 01 | CA | US DEPT OF LABOR | OTHER | GR0064540 | 05 | CA | MEDICAID |