Provider Demographics
NPI:1396040226
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:707-525-6925
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:707-575-6049
Mailing Address - Fax:707-523-3024
Practice Address - Street 1:1701 4TH ST
Practice Address - Street 2:STE 120
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-3661
Practice Address - Country:US
Practice Address - Phone:707-523-7025
Practice Address - Fax:707-523-3024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-25
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic SurgeryGroup - Multi-Specialty
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1396040226Medicaid
CACN8040OtherRAILROAD MEDICARE
CAZZZ38629ZOtherBLUE SHIELD
CACN8040OtherRAILROAD MEDICARE