Provider Demographics
NPI:1336126499
Name:ST MORITZ MEDICAL CENTER INC
Entity Type:Organization
Organization Name:ST MORITZ MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:FOSHAGEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:530-264-7475
Mailing Address - Street 1:202 PROVIDENCE MINE RD STE 105
Mailing Address - Street 2:
Mailing Address - City:NEVADA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95959-2945
Mailing Address - Country:US
Mailing Address - Phone:530-264-7475
Mailing Address - Fax:916-318-6950
Practice Address - Street 1:202 PROVIDENCE MINE RD STE 105
Practice Address - Street 2:
Practice Address - City:NEVADA CITY
Practice Address - State:CA
Practice Address - Zip Code:95959-2945
Practice Address - Country:US
Practice Address - Phone:530-264-7475
Practice Address - Fax:916-318-6950
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. MORITZ MEDICAL CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-12-29
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
CA20A4866207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ22662ZMedicare ID - Type Unspecified