Basic Information
| Provider Information | |||||||||
| NPI: | 1962587444 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REDWOOD REGIONAL MEDICAL GROUP, INC. | ||||||||
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| OtherOrganizationName: | REDWOOD REGIONAL ONCOLOGY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3555 ROUND BARN CIR | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954031757 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075281050 | ||||||||
| FaxNumber: | 7075253874 | ||||||||
| Practice Location | |||||||||
| Address1: | 3555 ROUND BARN CIR | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954031757 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075281050 | ||||||||
| FaxNumber: | 7075253874 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 11/15/2007 | ||||||||
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| AuthorizedOfficialLastName: | SCHMIDT | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | H. | ||||||||
| AuthorizedOfficialTitleorPosition: | M.D./RADIOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 7075464062 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | CLF4115 | CA | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | GR004920C | 05 | CA | MEDICAID | GR0049202 | 05 | CA | MEDICAID |