Healthcare Provider Details

I. General information

NPI: 1114465614
Provider Name (Legal Business Name): NORTHERN CALIFORNIA MEDICAL ASSOC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2017
Last Update Date: 04/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 HEALDSBURG AVE
HEALDSBURG CA
95448-3613
US

IV. Provider business mailing address

3536 MENDOCINO AVE STE 200
SANTA ROSA CA
95403-3634
US

V. Phone/Fax

Practice location:
  • Phone: 707-358-0222
  • Fax: 707-385-0109
Mailing address:
  • Phone: 707-525-6485
  • Fax: 707-573-6918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberC54138
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberC54138
License Number StateCA

VIII. Authorized Official

Name: RUTH A. SKIDMORE
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 707-573-6933