Healthcare Provider Details

I. General information

NPI: 1164705174
Provider Name (Legal Business Name): NORTHERN CALIFORNIA MEDICAL ASSOC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2011
Last Update Date: 03/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4761 HOEN AVE
SANTA ROSA CA
95405-7862
US

IV. Provider business mailing address

3536 MENDOCINO AVE 200
SANTA ROSA CA
95403-3634
US

V. Phone/Fax

Practice location:
  • Phone: 707-545-0570
  • Fax: 707-545-0575
Mailing address:
  • Phone: 707-575-6049
  • Fax: 707-545-0575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: MS. RUTH SKIDMORE
Title or Position: CHEIF EXECUTIVE OFFICER
Credential:
Phone: 707-573-6933