Provider Demographics
NPI:1740602309
Name:ANNADEL MEDICAL GROUP
Entity Type:Organization
Organization Name:ANNADEL MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:BOB
Authorized Official - Middle Name:
Authorized Official - Last Name:JUST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-303-8307
Mailing Address - Street 1:1165 MONTGOMERY DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4801
Mailing Address - Country:US
Mailing Address - Phone:707-303-8307
Mailing Address - Fax:707-303-1992
Practice Address - Street 1:1165 MONTGOMERY DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4801
Practice Address - Country:US
Practice Address - Phone:707-303-8307
Practice Address - Fax:707-303-1992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-15
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG22056174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty