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General NPI Number Information
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NPI Number | 1740602309
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Entity Type | Organization
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Legal Business Name | ANNADEL MEDICAL GROUP
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Dates
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Enumeration Date | 01/15/2014
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Last Update Date | 01/15/2014
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Provider Practice Location Address
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Address Line | 1165 MONTGOMERY DR
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City | SANTA ROSA
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State | CA
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Zip | 95405-4801
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Country | US
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Telephone | 707-303-8307
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Fax | 707-303-1992
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Provider Business Mailing Address
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Address Line | 1165 MONTGOMERY DR
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City | SANTA ROSA
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State | CA
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Zip | 95405-4801
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Country | US
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Telephone | 707-303-8307
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Fax | 707-303-1992
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Authorized Official
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Title or Position | COO
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Name | BOB JUST
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Credential |
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Telephone | 707-303-8307
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | G22056
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License Number State | CA
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