Provider Demographics
NPI:1033262381
Name:EEL RIVER VALLEY SURGICAL GROUP
Entity Type:Organization
Organization Name:EEL RIVER VALLEY SURGICAL GROUP
Other - Org Name:EEL RIVER VALLEY SURGICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:T
Authorized Official - Last Name:HASSAPIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-725-9301
Mailing Address - Street 1:3301 RENNER DR
Mailing Address - Street 2:
Mailing Address - City:FORTUNA
Mailing Address - State:CA
Mailing Address - Zip Code:95540-3119
Mailing Address - Country:US
Mailing Address - Phone:707-725-9301
Mailing Address - Fax:707-725-6099
Practice Address - Street 1:3301 RENNER DR
Practice Address - Street 2:
Practice Address - City:FORTUNA
Practice Address - State:CA
Practice Address - Zip Code:95540-3119
Practice Address - Country:US
Practice Address - Phone:707-725-9301
Practice Address - Fax:707-725-6099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0082870Medicaid
CAZZZ56802ZOtherBLUE SHIELD GROUP ID
CAZZZ14937ZMedicare ID - Type UnspecifiedGROUP ID NUMBER