Provider Demographics
NPI:1588220636
Name:NORTHERN CALIFORNIA MEDICAL ASSOC
Entity Type:Organization
Organization Name:NORTHERN CALIFORNIA MEDICAL ASSOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS SERVICES MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:DEWALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-525-6485
Mailing Address - Street 1:3536 MENDOCINO AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-3634
Mailing Address - Country:US
Mailing Address - Phone:707-782-9123
Mailing Address - Fax:707-782-9622
Practice Address - Street 1:1116 B ST
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-4054
Practice Address - Country:US
Practice Address - Phone:707-782-9123
Practice Address - Fax:707-782-9622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-14
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty