Provider Demographics
NPI:1215002852
Name:SANTA ROSA AMBULATORY SURGICAL CENTER MEDICAL GROUP INC
Entity Type:Organization
Organization Name:SANTA ROSA AMBULATORY SURGICAL CENTER MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:SOPHIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PAPPAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-523-4907
Mailing Address - Street 1:76 BROOKWOOD AVE STE B
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-4312
Mailing Address - Country:US
Mailing Address - Phone:707-523-4907
Mailing Address - Fax:707-523-4953
Practice Address - Street 1:76 BROOKWOOD AVE STE B
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4312
Practice Address - Country:US
Practice Address - Phone:707-523-4907
Practice Address - Fax:707-523-4953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ25482ZMedicare ID - Type Unspecified