Healthcare Provider Details

I. General information

NPI: 1033152350
Provider Name (Legal Business Name): CHASE DENNIS EMERGENCY MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 10/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1165 MONTGOMERY DR
SANTA ROSA CA
95405-4801
US

IV. Provider business mailing address

PO BOX 634718
CINCINNATI OH
45263-4718
US

V. Phone/Fax

Practice location:
  • Phone: 925-924-1600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. KRISTOPHER M SMITH
Title or Position: CFO
Credential:
Phone: 925-924-1600