Healthcare Provider Details

I. General information

NPI: 1619236452
Provider Name (Legal Business Name): NORTHERN CALIFORNIA MINIMALLY INVASIVE CARDIOVASCULAR SURGERY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2012
Last Update Date: 09/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 DOYLE PARK DR SUITE G-05
SANTA ROSA CA
95405-4558
US

IV. Provider business mailing address

3010 BEARD RD
NAPA CA
94558-3442
US

V. Phone/Fax

Practice location:
  • Phone: 707-576-7100
  • Fax:
Mailing address:
  • Phone: 707-255-8825
  • Fax: 707-252-9325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberA79076
License Number StateCA

VIII. Authorized Official

Name: RAMZI DEEIK
Title or Position: PRESIDENT
Credential: MD
Phone: 707-255-8825