Healthcare Provider Details

I. General information

NPI: 1649466004
Provider Name (Legal Business Name): SUTTER MEDICAL GROUP OF THE REDWOODS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 SONOMA AVE BUILDING 3
SANTA ROSA CA
95405-4817
US

IV. Provider business mailing address

15620 HEALDSBURG AVE
HEALDSBURG CA
95448-9617
US

V. Phone/Fax

Practice location:
  • Phone: 707-545-5200
  • Fax: 707-545-5234
Mailing address:
  • Phone: 707-473-4531
  • Fax: 707-473-4559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: LISA M PHILLIPS
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 707-473-4531