Healthcare Provider Details

I. General information

NPI: 1033341292
Provider Name (Legal Business Name): NORTH COAST FACULTY MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2009
Last Update Date: 09/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4135 MAIN ST
KELSEYVILLE CA
95451-8941
US

IV. Provider business mailing address

3883 AIRWAY DR SUITE 300
SANTA ROSA CA
95403-1670
US

V. Phone/Fax

Practice location:
  • Phone: 707-279-1888
  • Fax: 707-279-2832
Mailing address:
  • Phone: 707-521-8809
  • Fax: 707-521-8835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. STEVEN E LEVENBERG
Title or Position: PRESIDENT
Credential: DO
Phone: 707-521-8879