Provider Demographics
NPI:1407073919
Name:SACRAMENTO EAR NOSE AND THROAT SURGICAL MEDICAL GROUP INC
Entity Type:Organization
Organization Name:SACRAMENTO EAR NOSE AND THROAT SURGICAL MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:DUDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-736-3408
Mailing Address - Street 1:1561 CREEKSIDE DR
Mailing Address - Street 2:STE 180
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-3492
Mailing Address - Country:US
Mailing Address - Phone:916-984-8830
Mailing Address - Fax:916-984-8834
Practice Address - Street 1:3810 J ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5521
Practice Address - Country:US
Practice Address - Phone:916-736-3408
Practice Address - Fax:916-233-4171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ91298ZMedicare ID - Type Unspecified