Basic Information
| Provider Information | |||||||||
| NPI: | 1972704542 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUTTER MEDICAL FOUNDATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15620 HEALDSBURG AVE | ||||||||
| Address2: | |||||||||
| City: | HEALDSBURG | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954489617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074734531 | ||||||||
| FaxNumber: | 7074734559 | ||||||||
| Practice Location | |||||||||
| Address1: | 3536 MENDOCINO AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954033634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075711280 | ||||||||
| FaxNumber: | 7075785849 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | PHILLIPS | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 7074734531 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | CA | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | CA | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RE0101X | CA | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207V00000X | CA | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208000000X | CA | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 2080N0001X | CA | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | 208600000X | CA | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 2086S0129X | CA | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 291U00000X | CA | X | Laboratories | Clinical Medical Laboratory |
No ID Information.