=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831200815
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NOVAMED SURGERY CENTER OF SANTA ROSA, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1720 4TH ST
-----------------------------------------------------
City | SANTA ROSA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95404-3602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-546-8100
-----------------------------------------------------
Fax | 707-544-6438
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1720 4TH ST
-----------------------------------------------------
City | SANTA ROSA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95404-3602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-546-8100
-----------------------------------------------------
Fax | 707-544-6438
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE VP & CFO
-----------------------------------------------------
Name | MR. SCOTT T. MACOMBER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 312-780-3234
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | APPLIED FOR
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------