Healthcare Provider Details

I. General information

NPI: 1548409378
Provider Name (Legal Business Name): COMMUNITY NEONATOLOGY OF SACRAMENTO MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2009
Last Update Date: 02/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6501 COYLE AVE
CARMICHAEL CA
95608-0306
US

IV. Provider business mailing address

PO BOX 1359
SAN CLEMENTE CA
92674-1359
US

V. Phone/Fax

Practice location:
  • Phone: 916-537-5135
  • Fax:
Mailing address:
  • Phone: 949-492-3514
  • Fax: 949-366-2390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number3166137
License Number StateCA

VIII. Authorized Official

Name: KARA NORDBERG
Title or Position: ACCOUNTS ADMINISTRATOR
Credential:
Phone: 949-492-3514