Physician Compare National (NPI:1104824994)

HEALTHCARE PROVIDER: JACK WAXMAN M.D.

Physician Compare National contains general information about individual eligible professionals (EPs) such as demographic information and Medicare quality program participation.

Individual Professional Information
NPI	1104824994
	Unique healthcare provider (clinician) ID assigned by NPPES
PECOS UID	8921179516
	Unique individual clinician ID assigned by PECOS
Professional Enrollment ID	I20080625000765
	Unique ID for the individual professional enrollment that is the source for the data in the observation
Provider Last Name	WAXMAN
	Individual professional last name
Provider First Name	JACK
	Individual professional first name
Provider Gender	M
	The provider's gender if the provider is a person.

Medical School Information
Medical School Name	JS WEILL MEDICAL COLLEGE, CORNELL UNIVERSITY
	Individual professional's medical school
Graduation Year	1968
	Individual professional's medical school graduation year
Primary Specialty	RHEUMATOLOGY
	Primary medical specialty reported by the individual professional in the selected enrollment

Practice Information
Organization Legal Name	NORTHERN CALIFORNIA MEDICAL ASSOC INC
	Legal name of the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
Group Practice PAC ID	5597678490
	Unique Group Practice ID assigned by PECOS to the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
Number of Group Practice members	64
	Total number of individual professionals affiliated with the Group Practice based on Group Practice PAC ID
Line 1 Street Address	3536 MENDOCINO AVE
	Group Practice or individual's line 1 address
Line 2 Street Address	SUITE 300
	Group Practice or individual's line 2 address
City	SANTA ROSA
	Group Practice or individual's city
State	CA
	Group Practice or individual's state
Zip Code	954033634
	Group Practice or individual's zip code (9 digits when available)

Hospital(s) Affiliation Information
Hospital Affiliation CCN 1	050174
	Medicare CCN of hospital where individual professional provides service 1
Hospital Affiliation LBN 1	SANTA ROSA MEMORIAL HOSPITAL
	Legal business name of hospital where individual professional provides service 1
Hospital Affiliation CCN 2	050301
	Medicare CCN of hospital where individual professional provides service 2
Hospital Affiliation LBN 2	ADVENTIST HEALTH UKIAH VALLEY
	Legal business name of hospital where individual professional provides service 2
Hospital Affiliation CCN 3	051317
	Medicare CCN of hospital where individual professional provides service 3
Hospital Affiliation LBN 3	ADVENTIST HEALTH CLEARLAKE
	Legal business name of hospital where individual professional provides service 3
Hospital Affiliation CCN 4	050136
	Medicare CCN of hospital where individual professional provides service 4
Hospital Affiliation LBN 4	PETALUMA VALLEY HOSPITAL
	Legal business name of hospital where individual professional provides service 4
Hospital Affiliation CCN 5	051329
	Medicare CCN of hospital where individual professional provides service 5
Hospital Affiliation LBN 5	SUTTER LAKESIDE HOSPITAL
	Legal business name of hospital where individual professional provides service 5
Professional Accepts Medicare Assignment	Y

Physician Compare National (NPI:1104824994)

HEALTHCARE PROVIDER: JACK WAXMAN M.D.

Individual Professional Information

Medical School Information

Practice Information

Hospital(s) Affiliation Information