Healthcare Provider Details

I. General information

NPI: 1558658377
Provider Name (Legal Business Name): ADVENTIST HEALTH CALIFORNIA MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2011
Last Update Date: 06/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

821 S. ST. HELENA HIGHWAY
SAINT HELENA CA
94574-2266
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 707-963-5006
  • Fax: 707-963-5083
Mailing address:
  • Phone: 707-968-2809
  • Fax: 707-963-9185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

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