MEDICARE: SANTA ROSA ORTHOPAEDIC MEDICAL GROUP, INC.

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	207XS0106X	Orthopaedic Hand Surgery Physician
2	207XX0004X	Orthopaedic Foot and Ankle Surgery Physician
3	225XH1200X	Hand Occupational Therapist
4	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician
5	225100000X	Physical Therapist
6	208100000X	Physical Medicine & Rehabilitation Physician
7	207XX0801X	Orthopaedic Trauma Physician
8	207X00000X	Orthopaedic Surgery 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
2	ZZZ92332Z	OTHER	CA	BLUE SHIELD GRP # 1405
3	1518907336	OTHER		NPI
4	379618500	OTHER	CA	US DEPT OF LABOR (OWCP)

General Provider Information

NPI Number	:	1518907336
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SANTA ROSA ORTHOPAEDIC MEDICAL GROUP, INC.

Provider Business Mailing Address
First Line	:	1701 4TH ST STE 200
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95404-3661
Country	:	US
Telephone Number	:	707-546-1922
Fax Number	:	707-528-1602

Provider Business Practice Location Address
First Line	:	1701 4TH ST STE 200
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95404-3661
Country	:	US
Telephone Number	:	707-546-1922
Fax Number	:	707-528-1602

Authorized Official
Title or Position	:	CONTRACTING CREDENTIALING ASSOCIATE
Name	:	EVANGELINE VLACOS
Credential	:
Telephone Number	:	510-387-2193

Provider Enumeration Date	:	06/08/2006
Last Update Date	:	05/20/2026

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Directions to “SANTA ROSA ORTHOPAEDIC MEDICAL GROUP, INC. ” Practice Location

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