Provider Demographics
NPI:1861626129
Name:SHASTA REGIONAL MEDICAL GROUP INC
Entity Type:Organization
Organization Name:SHASTA REGIONAL MEDICAL GROUP INC
Other - Org Name:SHASTA COMMUNITY MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:VENKAMMA
Authorized Official - Middle Name:
Authorized Official - Last Name:REDDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-241-8000
Mailing Address - Street 1:16850 BEAR VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-5794
Mailing Address - Country:US
Mailing Address - Phone:760-241-8000
Mailing Address - Fax:760-962-8021
Practice Address - Street 1:1555 EAST ST STE 210
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-1153
Practice Address - Country:US
Practice Address - Phone:530-244-8316
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-14
Last Update Date:2009-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA266332086S0129X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty