Provider Demographics
NPI:1225330459
Name:NORTHERN CALIFORNIA MEDICAL ASSOC INC
Entity Type:Organization
Organization Name:NORTHERN CALIFORNIA MEDICAL ASSOC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:A
Authorized Official - Last Name:SKIDMORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-573-6925
Mailing Address - Street 1:3536 MENDOCINO AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-3634
Mailing Address - Country:US
Mailing Address - Phone:707-575-6049
Mailing Address - Fax:707-573-6918
Practice Address - Street 1:153 W SPRUCE ST
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437-3024
Practice Address - Country:US
Practice Address - Phone:707-462-1516
Practice Address - Fax:707-462-1178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-19
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ36793ZOtherBLUE SHIELD
CA1225330459Medicaid
CAZZZ36793ZOtherBLUE SHIELD