Provider Demographics
NPI:1467478818
Name:ENDOSCOPY CENTER OF SANTA ROSA
Entity Type:Organization
Organization Name:ENDOSCOPY CENTER OF SANTA ROSA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARION
Authorized Official - Middle Name:
Authorized Official - Last Name:AULD
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:707-571-2192
Mailing Address - Street 1:1200 SONOMA AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-6664
Mailing Address - Country:US
Mailing Address - Phone:707-571-2192
Mailing Address - Fax:707-571-2194
Practice Address - Street 1:1200 SONOMA AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-6664
Practice Address - Country:US
Practice Address - Phone:707-571-2192
Practice Address - Fax:707-571-2194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAS1557OtherBLUE CROSS
CAZZZH49112OtherBLUE SHIELD
CAZZZ23479ZMedicare UPIN