Provider Demographics
NPI:1548237175
Name:INTERNAL MEDICINE ASSOCIATES OF SANTA ROSA MEDICAL GROUP INC
Entity Type:Organization
Organization Name:INTERNAL MEDICINE ASSOCIATES OF SANTA ROSA MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:N
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-544-3411
Mailing Address - Street 1:500 DOYLE PARK DR
Mailing Address - Street 2:G03
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405
Mailing Address - Country:US
Mailing Address - Phone:707-544-3411
Mailing Address - Fax:707-544-0834
Practice Address - Street 1:500 DOYLE PARK DR
Practice Address - Street 2:G03
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405
Practice Address - Country:US
Practice Address - Phone:707-544-3411
Practice Address - Fax:707-544-0834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CJ3211OtherRR MCR
CAGR0044960Medicaid
ZZZ058282OtherBCBS
CAGR0044960Medicaid