Provider Demographics
NPI:1407970544
Name:SUTTER MEDICAL GROUP OF THE REDWOODS
Entity Type:Organization
Organization Name:SUTTER MEDICAL GROUP OF THE REDWOODS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:E
Authorized Official - Last Name:ROCKSTROH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-521-8809
Mailing Address - Street 1:3883 AIRWAY DR
Mailing Address - Street 2:SANTA ROSA
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-1670
Mailing Address - Country:US
Mailing Address - Phone:707-521-8809
Mailing Address - Fax:707-521-8835
Practice Address - Street 1:1200 SONOMA AVE
Practice Address - Street 2:SUITE 6
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-6664
Practice Address - Country:US
Practice Address - Phone:707-545-2545
Practice Address - Fax:707-545-1829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA208000000X, 2080N0001X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ04917ZMedicare PIN