Provider Demographics
NPI:1245411529
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:707-525-6485
Mailing Address - Fax:707-573-6918
Practice Address - Street 1:104 LYNCH CREEK WAY
Practice Address - Street 2:STE 10
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-2355
Practice Address - Country:US
Practice Address - Phone:707-782-9123
Practice Address - Fax:707-782-9622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-15
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ51563YOtherBLUE SHIELD
CA1245411529Medicaid
CAZZZ06724ZMedicare PIN