=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871371740
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SIERRA MEDICAL PARTNERSHIP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2023
-----------------------------------------------------
Last Update Date | 09/20/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1600 CREEKSIDE DR STE 2500
-----------------------------------------------------
City | FOLSOM
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95630-3485
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-542-1458
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1625 CREEKSIDE DR STE 202
-----------------------------------------------------
City | FOLSOM
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95630-3819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-663-2100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING
-----------------------------------------------------
Name | ELIZABETH SCRIVEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 916-663-2100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------