MEDICARE: NORTH BAY MEDICAL GROUP SURGERY CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center	AS1628	CA

General Provider Information

NPI Number	:	1639220189
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTH BAY MEDICAL GROUP SURGERY CENTER

Provider Business Mailing Address
First Line	:	3850 MONTGOMERY DR
Second Line	:	SUITE D
City	:	SANTA ROSA
State	:	CA
Zip	:	95405-5207
Country	:	US
Telephone Number	:	707-591-0619
Fax Number	:	707-591-0617

Provider Business Practice Location Address
First Line	:	4415 SONOMA HWY
Second Line	:	SUITE B
City	:	SANTA ROSA
State	:	CA
Zip	:	95409-7100
Country	:	US
Telephone Number	:	707-591-0619
Fax Number	:	707-591-0617

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ERIC JAMES KRAUT
Credential	:	M.D.
Telephone Number	:	707-591-0619

Provider Enumeration Date	:	01/12/2007
Last Update Date	:	07/21/2008

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