Healthcare Provider Details

I. General information

NPI: 1588803373
Provider Name (Legal Business Name): SUTTER GOULD MEDICAL FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2009
Last Update Date: 08/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1409 E BRIGGSMORE AVE
MODESTO CA
95355-2707
US

IV. Provider business mailing address

600 COFFEE RD
MODESTO CA
95355-4201
US

V. Phone/Fax

Practice location:
  • Phone: 209-524-1211
  • Fax:
Mailing address:
  • Phone: 209-524-1211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License Number10022
License Number StateCA

VIII. Authorized Official

Name: STEVEN A MITNICK
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 209-521-6097