Provider Demographics
NPI:1194836338
Name:AMETHYST MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:AMETHYST MEDICAL GROUP, INC.
Other - Org Name:AMETHYST MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WINIFRED
Authorized Official - Middle Name:MYRNA
Authorized Official - Last Name:LOESCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:530-798-5003
Mailing Address - Street 1:590 SEARLS AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEVADA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95959-3043
Mailing Address - Country:US
Mailing Address - Phone:530-798-5003
Mailing Address - Fax:530-271-2338
Practice Address - Street 1:590 SEARLS AVE
Practice Address - Street 2:SUITE A
Practice Address - City:NEVADA CITY
Practice Address - State:CA
Practice Address - Zip Code:95959-3043
Practice Address - Country:US
Practice Address - Phone:530-798-5003
Practice Address - Fax:530-271-2338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC42292207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C422920OtherPPIN
CA00C422920OtherPPIN
CAZZZ25085ZMedicare ID - Type UnspecifiedGROUP ID