Provider Demographics
NPI:1508052572
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:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-473-4531
Mailing Address - Street 1:15620 HEALDSBURG AVE
Mailing Address - Street 2:
Mailing Address - City:HEALDSBURG
Mailing Address - State:CA
Mailing Address - Zip Code:95448-9617
Mailing Address - Country:US
Mailing Address - Phone:707-473-4531
Mailing Address - Fax:707-473-4559
Practice Address - Street 1:625 STEELE LN
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-3127
Practice Address - Country:US
Practice Address - Phone:707-576-4800
Practice Address - Fax:707-576-4825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty