Healthcare Provider Details

I. General information

NPI: 1710110754
Provider Name (Legal Business Name): NORTH COAST FACULTY MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2009
Last Update Date: 10/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 PETALUMA AVE
SEBASTOPOL CA
95472-4224
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 707-829-8426
  • Fax: 707-829-6675
Mailing address:
  • Phone: 707-521-8809
  • Fax: 707-521-8835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. STEVEN E LEVENBERG
Title or Position: PRESIDENT
Credential: DO
Phone: 707-521-8879