Healthcare Provider Details

I. General information

NPI: 1861626129
Provider Name (Legal Business Name): SHASTA REGIONAL MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2009
Last Update Date: 05/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1555 EAST ST STE 210
REDDING CA
96001-1153
US

IV. Provider business mailing address

16850 BEAR VALLEY RD
VICTORVILLE CA
92395-5794
US

V. Phone/Fax

Practice location:
  • Phone: 530-244-8316
  • Fax:
Mailing address:
  • Phone: 760-241-8000
  • Fax: 760-962-8021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number26633
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number26633
License Number StateCA

VIII. Authorized Official

Name: MRS. VENKAMMA REDDY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 760-241-8000