Healthcare Provider Details

I. General information

NPI: 1689226649
Provider Name (Legal Business Name): NORTHERN CALIFORNIA MEDICAL ASSOC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2019
Last Update Date: 07/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 4TH ST STE 100
SANTA ROSA CA
95404-3661
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 707-569-3234
  • Fax:
Mailing address:
  • Phone: 707-545-6485
  • Fax: 707-573-6918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0008X
TaxonomyHepatology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: SALLY A DEWALD
Title or Position: BUSINESS SERVICES MANAGER
Credential:
Phone: 707-525-6485