Healthcare Provider Details

I. General information

NPI: 1699054650
Provider Name (Legal Business Name): ADVENTIST HEALTH CALIFORNIA MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2011
Last Update Date: 08/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18990 COYOTE VALLEY RD SUITE 5
HIDDEN VALLEY LAKE CA
95467-8337
US

IV. Provider business mailing address

1001 ADAMS ST SUITE 102
SAINT HELENA CA
94574-1107
US

V. Phone/Fax

Practice location:
  • Phone: 707-987-9024
  • Fax: 707-987-9152
Mailing address:
  • Phone: 707-968-2809
  • Fax: 707-963-9185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KAYE A DONNELLY
Title or Position: SPECIALIST, CONTRACT COMPLIANCE
Credential:
Phone: 707-968-2809