Healthcare Provider Details

I. General information

NPI: 1174925697
Provider Name (Legal Business Name): SPINE AND NEUROSURGICAL TRAUMA ASSOCIATES OF NORTHERN CALIFORNIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2014
Last Update Date: 09/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4690 HOEN AVE
SANTA ROSA CA
95405-7823
US

IV. Provider business mailing address

1275 4TH ST PMB 646
SANTA ROSA CA
95404-4057
US

V. Phone/Fax

Practice location:
  • Phone: 707-799-5911
  • Fax:
Mailing address:
  • Phone: 707-799-5911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number13305
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License Number13305
License Number StateCA

VIII. Authorized Official

Name: DR. SCOTT GLICKMAN
Title or Position: PRESIDENT
Credential: DO
Phone: 707-799-5911