Provider Demographics
NPI:1033103676
Name:PACIFIC REDWOOD MEDICAL GROUP INC
Entity Type:Organization
Organization Name:PACIFIC REDWOOD MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:W
Authorized Official - Last Name:FAUSONE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-462-7900
Mailing Address - Street 1:PO BOX 2800
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-2800
Mailing Address - Country:US
Mailing Address - Phone:707-462-7900
Mailing Address - Fax:707-462-7947
Practice Address - Street 1:275 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482
Practice Address - Country:US
Practice Address - Phone:707-462-7900
Practice Address - Fax:707-462-7947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-09
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency MedicineGroup - Multi-Specialty
No2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental MedicineGroup - Multi-Specialty
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational MedicineGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA17165692005OtherSTATE COMPENSATION INS
CAGR0093400Medicaid
352149100OtherDOL (DEPT OF LABOR)
CAZZZ06060ZOtherBLUE SHIELD
352149100OtherDOL (DEPT OF LABOR)
CAGR0093400Medicaid