Healthcare Provider Details

I. General information

NPI: 1033103676
Provider Name (Legal Business Name): PACIFIC REDWOOD MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 07/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 HOSPITAL DR
UKIAH CA
95482
US

IV. Provider business mailing address

PO BOX 2800
UKIAH CA
95482-2800
US

V. Phone/Fax

Practice location:
  • Phone: 707-462-7900
  • Fax: 707-462-7947
Mailing address:
  • Phone: 707-462-7900
  • Fax: 707-462-7947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. GARY W FAUSONE
Title or Position: PRESIDENT
Credential: MD
Phone: 707-462-7900