Provider Demographics
| NPI: | 1346575073 |
|---|---|
| Name: | SUTTER WEST BAY MEDICAL FOUNDATION |
| Entity Type: | Organization |
| Organization Name: | SUTTER WEST BAY MEDICAL FOUNDATION |
| Other - Org Name: | SUTTER PACIFIC MEDICAL FOUNDATION |
| Other - Org Type: | Doing Business As |
| Authorized Official - Title/Position: | CHIEF FINANCIAL OFFICER |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | JOHN |
| Authorized Official - Middle Name: | B |
| Authorized Official - Last Name: | GATES |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 4156-000-7771 |
| Mailing Address - Street 1: | 1700 CALIFORNIA STREET |
| Mailing Address - Street 2: | SUITE 530 |
| Mailing Address - City: | SAN FRANCISCO |
| Mailing Address - State: | CA |
| Mailing Address - Zip Code: | 94109-4591 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | |
| Mailing Address - Fax: | |
| Practice Address - Street 1: | 3883 AIRWAY DRIVE |
| Practice Address - Street 2: | SUITE 120 |
| Practice Address - City: | SANTA ROSA |
| Practice Address - State: | CA |
| Practice Address - Zip Code: | 95403-1678 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 707-521-8966 |
| Practice Address - Fax: | 707-523-1301 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | Yes |
| Parent Organization LBN: | SUTTER WEST BAY MEDICAL FOUNDATION |
| Parent Organization TIN: | <UNAVAIL> |
| Enumeration Date: | 2009-10-14 |
| Last Update Date: | 2010-05-21 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 207P00000X | Allopathic & Osteopathic Physicians | Emergency Medicine | Group - Multi-Specialty | |
| No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
| No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
| No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
| No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
| No | 208D00000X | Allopathic & Osteopathic Physicians | General Practice | Group - Multi-Specialty | |
| No | 213E00000X | Podiatric Medicine & Surgery Service Providers | Podiatrist | Group - Multi-Specialty | |
| No | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Group - Multi-Specialty | |
| No | 247100000X | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Group - Multi-Specialty | |
| No | 291U00000X | Laboratories | Clinical Medical Laboratory | Group - Multi-Specialty | |
| No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
| No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty | |
| No | 367A00000X | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| CA | GR0055425 | Medicaid | |
| CA | GR00055421 | Medicaid | |
| CA | GR0091420 | Medicaid | |
| CA | GR0055425 | Medicaid |
