Healthcare Provider Details

I. General information

NPI: 1124252416
Provider Name (Legal Business Name): SUTTER WEST BAY MEDICAL FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2009
Last Update Date: 09/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 LAS GALLINAS AVE #210
SAN RAFAEL CA
94903-3438
US

IV. Provider business mailing address

PO BOX 254947
SACRAMENTO CA
95865-4947
US

V. Phone/Fax

Practice location:
  • Phone: 415-479-7244
  • Fax: 415-479-0917
Mailing address:
  • Phone: 916-854-6975
  • Fax: 916-854-6844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: JOHN GATES
Title or Position: RCFO
Credential: MD
Phone: 415-600-7755