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NPI Code Detail

MEDICARE: NORTHERN CALIFORNIA MEDICAL ASSOC INC

MEDICARE: NORTHERN CALIFORNIA MEDICAL ASSOC INC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207RC0000XCardiovascular Disease Physician

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1ZZZ00204ZOTHERCABLUE SHIELD OF CALIFORNIA
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1073512661
Entity Type Code : Organization
Provider Name (Legal Business Name) : NORTHERN CALIFORNIA MEDICAL ASSOC INC
Provider Business Mailing Address
First Line : 3536 MENDOCINO AVE
Second Line : STE 200
City : SANTA ROSA
State : CA
Zip : 95403-3634
Country : US
Telephone Number : 707-525-6485
Fax Number : 707-573-6165
Provider Business Practice Location Address
First Line : 717 CENTER ST
Second Line :
City : HEALDSBURG
State : CA
Zip : 95448-3604
Country : US
Telephone Number : 707-433-7214
Fax Number : 707-433-8642
Authorized Official
Title or Position : CHIEF EXECUTIVE OFFICER
Name : MS. RUTH ANN SKIDMORE
Credential :
Telephone Number : 707-573-6925
Provider Enumeration Date : 07/18/2005
Last Update Date : 02/24/2012

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Directions to “NORTHERN CALIFORNIA MEDICAL ASSOC INC ” Practice Location

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