Healthcare Provider Details

I. General information

NPI: 1124277686
Provider Name (Legal Business Name): N COAST FACULTY MEDICAL GROUP DBA SUTTER MEDICAL GROUP OF THE REDWOODS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2008
Last Update Date: 08/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3883 AIRWAY DR
SANTA ROSA CA
95403-1670
US

IV. Provider business mailing address

3883 AIRWAY DR SUITE 300
SANTA ROSA CA
95403-1670
US

V. Phone/Fax

Practice location:
  • Phone: 707-521-8809
  • Fax: 707-521-8835
Mailing address:
  • Phone: 707-521-8809
  • Fax: 707-521-8835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. STEVEN E LEVENBERG
Title or Position: PRESIDENT, SMGR
Credential: D.O.
Phone: 707-521-8879