Healthcare Provider Details

I. General information

NPI: 1518907336
Provider Name (Legal Business Name): SANTA ROSA ORTHOPAEDIC MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 4TH ST STE 200
SANTA ROSA CA
95404-3661
US

IV. Provider business mailing address

1701 4TH ST STE 200
SANTA ROSA CA
95404-3661
US

V. Phone/Fax

Practice location:
  • Phone: 707-546-1922
  • Fax: 707-528-1602
Mailing address:
  • Phone: 707-546-1922
  • Fax: 707-528-1602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: EVANGELINE VLACOS
Title or Position: CONTRACTING CREDENTIALING ASSOCIATE
Credential:
Phone: 510-387-2193