Provider Demographics
NPI:1508931619
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:SUITE 300
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 1:5300 SNYDER LN
Practice Address - Street 2:SUITE A
Practice Address - City:ROHNERT PARK
Practice Address - State:CA
Practice Address - Zip Code:94928-2915
Practice Address - Country:US
Practice Address - Phone:707-585-8347
Practice Address - Fax:707-585-8056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207Q00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR00055421Medicaid
CAGR00055421Medicaid