Provider Demographics
NPI:1154440972
Name:SEBASTOPOL ASC, L.P.
Entity Type:Organization
Organization Name:SEBASTOPOL ASC, L.P.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:J
Authorized Official - Last Name:KAHLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-823-7628
Mailing Address - Street 1:6880 PALM AVE
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-4270
Mailing Address - Country:US
Mailing Address - Phone:707-823-7628
Mailing Address - Fax:707-823-1521
Practice Address - Street 1:6880 PALM AVE
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-4270
Practice Address - Country:US
Practice Address - Phone:707-823-7628
Practice Address - Fax:707-823-1521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA010000189261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASUR51098FMedicaid
CA551098OtherBLUE CROSS
1154440972OtherMEDICARE NPI
CA490002015OtherMEDICARE RET RAILROAD
CAZZZH4909ZOtherBLUE SHIELD
CASUR51098FMedicaid