Healthcare Provider Details

I. General information

NPI: 1558812875
Provider Name (Legal Business Name): NORTHERN CALIFORNIA MEDICAL ASSOC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2016
Last Update Date: 11/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2725 MENDOCINO AVE
SANTA ROSA CA
95403-2805
US

IV. Provider business mailing address

3536 MENDOCINO AVE STE 200
SANTA ROSA CA
95403-3634
US

V. Phone/Fax

Practice location:
  • Phone: 707-545-4537
  • Fax: 707-545-6726
Mailing address:
  • Phone: 707-525-6485
  • Fax: 707-573-6918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: RUTH A SKIDMORE
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 707-573-6933