Provider Demographics
NPI:1376545988
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:ANN
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 1:244 HOSPITAL DR
Practice Address - Street 2:STE B
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-4557
Practice Address - Country:US
Practice Address - Phone:707-463-8070
Practice Address - Fax:707-463-8075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-12
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear CardiologyGroup - Multi-Specialty
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ29381ZOtherBLUE SHIELD OF CALIFORNIA
CAGR0098390Medicaid
CAZZZ31444ZMedicare PIN