Provider Demographics
NPI:1639268667
Name:SUTTER MEDICAL GROUP OF THE REDWOODS
Entity Type:Organization
Organization Name:SUTTER MEDICAL GROUP OF THE REDWOODS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROCKSTROH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-521-8809
Mailing Address - Street 1:3883 AIRWAY DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-1670
Mailing Address - Country:US
Mailing Address - Phone:707-521-8809
Mailing Address - Fax:707-521-8835
Practice Address - Street 1:3317 CHANATE RD
Practice Address - Street 2:SUITE 2C
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-1737
Practice Address - Country:US
Practice Address - Phone:707-570-1130
Practice Address - Fax:707-571-2478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25179207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0055426Medicaid
CAZZZ42346ZMedicare ID - Type Unspecified