Provider Demographics
NPI:1821045055
Name:SIERRA NEVADA UROLOGY MEDICAL ASSOCIATES, INC.
Entity Type:Organization
Organization Name:SIERRA NEVADA UROLOGY MEDICAL ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITMORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-274-9623
Mailing Address - Street 1:107 MARGARET LN
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-5211
Mailing Address - Country:US
Mailing Address - Phone:530-274-9623
Mailing Address - Fax:530-274-0590
Practice Address - Street 1:107 MARGARET LN
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5211
Practice Address - Country:US
Practice Address - Phone:530-274-9623
Practice Address - Fax:530-274-0590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherTAX ID #
CA=========OtherTAX ID #