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General NPI Number Information
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NPI Number | 1174925697
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Entity Type | Organization
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Legal Business Name | SPINE AND NEUROSURGICAL TRAUMA ASSOCIATES OF NORTHERN CALIFORNIA
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Dates
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Enumeration Date | 09/17/2014
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Last Update Date | 09/17/2014
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Provider Practice Location Address
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Address Line | 4690 HOEN AVE
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City | SANTA ROSA
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State | CA
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Zip | 95405-7823
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Country | US
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Telephone | 707-799-5911
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Fax |
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Provider Business Mailing Address
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Address Line | 1275 4TH ST PMB 646
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City | SANTA ROSA
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State | CA
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Zip | 95404-4057
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Country | US
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Telephone | 707-799-5911
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. SCOTT GLICKMAN
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Credential | DO
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Telephone | 707-799-5911
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084V0102X
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Taxonomy Name | Vascular Neurology Physician
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License Number | 13305
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 207T00000X
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Taxonomy Name | Neurological Surgery Physician
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License Number | 13305
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License Number State | CA
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