Provider Demographics
NPI:1841204518
Name:REDWOOD REGIONAL MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:REDWOOD REGIONAL MEDICAL GROUP, INC.
Other - Org Name:REDWOOD REGIONAL ONCOLOGY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HELEN
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-546-4602
Mailing Address - Street 1:110 LYNCH CREEK WAY STE A
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-2337
Mailing Address - Country:US
Mailing Address - Phone:707-763-0600
Mailing Address - Fax:707-765-1757
Practice Address - Street 1:110 LYNCH CREEK WAY STE A
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-2337
Practice Address - Country:US
Practice Address - Phone:707-763-0600
Practice Address - Fax:707-765-1757
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REDWOOD REGIONAL MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-28
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RH0003X, 2085R0001X
CA05D0689028291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0049200Medicaid
CAGR004920BMedicaid
CAGR0049200Medicaid
CAGR004920BMedicaid