Healthcare Provider Details

I. General information

NPI: 1306043245
Provider Name (Legal Business Name): NORTHERN CALIFORNIA MEDICAL ASSOC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2007
Last Update Date: 02/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 HOSPITAL DR STE B
UKIAH CA
95482-4558
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 707-463-8070
  • Fax: 707-463-8075
Mailing address:
  • Phone: 707-525-6485
  • Fax: 707-573-6918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

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