MEDICARE: SANTA ROSA HEAD AND NECK SURGICAL GROUP, 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
1	207Y00000X	Otolaryngology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114969441
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SANTA ROSA HEAD AND NECK SURGICAL GROUP, INC

Provider Business Mailing Address
First Line	:	2451 SUMMERFIELD RD
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95405-7815
Country	:	US
Telephone Number	:	707-523-7025
Fax Number	:

Provider Business Practice Location Address
First Line	:	2451 SUMMERFIELD RD
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95405-7815
Country	:	US
Telephone Number	:	707-523-7025
Fax Number	:	707-591-0224

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DAVID QUENELLE
Credential	:	M.D.
Telephone Number	:	707-523-7025

Provider Enumeration Date	:	06/12/2006
Last Update Date	:	08/22/2020

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