Healthcare Provider Details

I. General information

NPI: 1710162292
Provider Name (Legal Business Name): SUTTER MEDICAL FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2008
Last Update Date: 05/30/2024
Certification Date: 05/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 STEELE LN
SANTA ROSA CA
95403-3127
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 707-576-4828
  • Fax:
Mailing address:
  • Phone: 707-576-4828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2471M2300X
TaxonomyMammography Radiologic Technologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KRISTA LOPES
Title or Position: SH VP, QUALITY, SAFETY, PATIENT EDU
Credential:
Phone: 916-384-7544