Healthcare Provider Details

I. General information

NPI: 1003985037
Provider Name (Legal Business Name): SURGICAL ASSOCIATES OF MONTEREY BAY MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 08/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1668 DOMINICAN WAY
SANTA CRUZ CA
95065-1522
US

IV. Provider business mailing address

1668 DOMINICAN WAY
SANTA CRUZ CA
95065-1522
US

V. Phone/Fax

Practice location:
  • Phone: 831-464-9962
  • Fax: 831-464-9933
Mailing address:
  • Phone: 831-464-9962
  • Fax: 831-464-9933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER SHOUP
Title or Position: ADMINISTRATIVE ASSISTANT
Credential:
Phone: 831-464-9962