MEDICARE: NORTHERN CALIFORNIA MEDICAL ASSOC INC

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	207RI0011X	Interventional Cardiology Physician
2	207RC0000X	Cardiovascular Disease Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ZZZ01804Z	OTHER	CA	BLUE SHIELD OF CALIFORNIA
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1689671570
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHERN CALIFORNIA MEDICAL ASSOC INC

Provider Business Mailing Address
First Line	:	3536 MENDOCINO AVE
Second Line	:	STE 200
City	:	SANTA ROSA
State	:	CA
Zip	:	95403-3634
Country	:	US
Telephone Number	:	707-525-6049
Fax Number	:	707-573-6918

Provider Business Practice Location Address
First Line	:	721 RIVER DR
Second Line	:	STE A
City	:	FORT BRAGG
State	:	CA
Zip	:	95437-5402
Country	:	US
Telephone Number	:	707-573-6166
Fax Number	:	707-573-6165

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MS. RUTH ANN SKIDMORE
Credential	:
Telephone Number	:	707-573-6925

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	02/09/2012

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