Basic Information
| Provider Information | |||||||||
| NPI: | 1982798096 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUTTER MEDICAL GROUP OF THE REDWOODS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3883 AIRWAY DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954031670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075218809 | ||||||||
| FaxNumber: | 7075218835 | ||||||||
| Practice Location | |||||||||
| Address1: | 3315 CHANATE RD | ||||||||
| Address2: | SUITE 1C | ||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954041736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075712486 | ||||||||
| FaxNumber: | 7075751872 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | ROCKSTROH | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 7075218809 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207RG0100X | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 208600000X | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 2086S0129X | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 207Q00000X | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR0005542A | 05 | CA | MEDICAID |