Healthcare Provider Details

I. General information

NPI: 1457534174
Provider Name (Legal Business Name): NORTHERN CALIFORNIA MEDICAL ASSOC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2007
Last Update Date: 02/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 4TH ST STE 200
SANTA ROSA CA
95404-3601
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 707-579-2100
  • Fax: 707-523-0616
Mailing address:
  • Phone: 707-525-6485
  • Fax: 707-523-0616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. RUTH A SKIDMORE
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 707-573-6925