Provider Demographics
NPI:1558476226
Name:SACRAMENTO UROLOGY MEDICAL CORPORATION
Entity Type:Organization
Organization Name:SACRAMENTO UROLOGY MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:HAINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-961-2514
Mailing Address - Street 1:6620 COYLE AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-6333
Mailing Address - Country:US
Mailing Address - Phone:916-961-2514
Mailing Address - Fax:916-961-0297
Practice Address - Street 1:6620 COYLE AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-6333
Practice Address - Country:US
Practice Address - Phone:916-961-2514
Practice Address - Fax:916-961-0297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA26739174400000X
CAA061116174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1619937463OtherNPI
CA1114987526OtherNPI
CACG8167OtherRAILROAD MEDICARE GRP ID
CAZZZ03518ZOtherBLUE SHIELD GROUP ID
CA1114987526OtherNPI
CAZZZ31371ZMedicare PIN
CAA87086Medicare UPIN
CA00A267390Medicare ID - Type Unspecified