Provider Demographics
NPI:1720212012
Name:SUTTER WEST BAY MEDICAL FOUNDATION
Entity Type:Organization
Organization Name:SUTTER WEST BAY MEDICAL FOUNDATION
Other - Org Name:SUTTER PACIFIC MEDICAL FOUNDATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RCFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:GATES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-600-7755
Mailing Address - Street 1:PO BOX 254947
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95865-4947
Mailing Address - Country:US
Mailing Address - Phone:916-854-6975
Mailing Address - Fax:916-854-6844
Practice Address - Street 1:3000 COLBY ST
Practice Address - Street 2:#205
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-2083
Practice Address - Country:US
Practice Address - Phone:510-776-4143
Practice Address - Fax:510-486-1478
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUTTER WEST BAY MEDICAL FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-05-14
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207RI0008XAllopathic & Osteopathic PhysiciansInternal MedicineHepatologyGroup - Multi-Specialty
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric EndocrinologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABF336AMedicare PIN