Provider Demographics
NPI:1265015978
Name:PROVIDENCE MEDICAL FOUNDATION
Entity Type:Organization
Organization Name:PROVIDENCE MEDICAL FOUNDATION
Other - Org Name:PROVIDENCE MEDICAL GROUP NORTHERN CALIFORNIA
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE
Authorized Official - Prefix:
Authorized Official - First Name:BOB
Authorized Official - Middle Name:
Authorized Official - Last Name:JUST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-303-8355
Mailing Address - Street 1:185 SOTOYOME ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4803
Mailing Address - Country:US
Mailing Address - Phone:707-303-8355
Mailing Address - Fax:707-303-2035
Practice Address - Street 1:185 SOTOYOME ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4803
Practice Address - Country:US
Practice Address - Phone:707-303-8355
Practice Address - Fax:707-303-2035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-30
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty