Provider Demographics
NPI:1639220189
Name:NORTH BAY MEDICAL GROUP SURGERY CENTER
Entity Type:Organization
Organization Name:NORTH BAY MEDICAL GROUP SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:KRAUT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-591-0619
Mailing Address - Street 1:3850 MONTGOMERY DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-5207
Mailing Address - Country:US
Mailing Address - Phone:707-591-0619
Mailing Address - Fax:707-591-0617
Practice Address - Street 1:4415 SONOMA HWY
Practice Address - Street 2:SUITE B
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95409-7100
Practice Address - Country:US
Practice Address - Phone:707-591-0619
Practice Address - Fax:707-591-0617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAS1628261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAX99342Medicare UPIN
CAZZZ27185ZMedicare ID - Type Unspecified