Provider Demographics
NPI:1588803373
Name:SUTTER GOULD MEDICAL FOUNDATION
Entity Type:Organization
Organization Name:SUTTER GOULD MEDICAL FOUNDATION
Other - Org Name:BRIGGSMORE SPECIALTY CENTER AMBULATORY SURGICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:MITNICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-521-6097
Mailing Address - Street 1:600 COFFEE RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-4201
Mailing Address - Country:US
Mailing Address - Phone:209-524-1211
Mailing Address - Fax:
Practice Address - Street 1:1409 E BRIGGSMORE AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-2707
Practice Address - Country:US
Practice Address - Phone:209-524-1211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-18
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QA1903X
CA10022261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ20487ZMedicare PIN