MEDICARE: SUTTER MEDICAL GROUP OF THE REDWOODS

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number State
1	207RE0101X	Endocrinology, Diabetes & Metabolism Physician	CA
2	207RG0100X	Gastroenterology Physician	CA
3	208600000X	Surgery Physician	CA
4	2086S0129X	Vascular Surgery Physician	CA
5	207Q00000X	Family Medicine Physician	CA

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	:	1982798096
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUTTER MEDICAL GROUP OF THE REDWOODS

Provider Business Mailing Address
First Line	:	3883 AIRWAY DR
Second Line	:	SUITE 300
City	:	SANTA ROSA
State	:	CA
Zip	:	95403-1670
Country	:	US
Telephone Number	:	707-521-8809
Fax Number	:	707-521-8835

Provider Business Practice Location Address
First Line	:	3315 CHANATE RD
Second Line	:	SUITE 1C
City	:	SANTA ROSA
State	:	CA
Zip	:	95404-1736
Country	:	US
Telephone Number	:	707-571-2486
Fax Number	:	707-575-1872

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	LINDA E ROCKSTROH
Credential	:
Telephone Number	:	707-521-8809

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	07/21/2022

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