Provider Demographics
NPI:1891793741
Name:ERNY, RAYMOND EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:EDWARD
Last Name:ERNY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3536 MENDOCINO AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-3634
Mailing Address - Country:US
Mailing Address - Phone:707-585-6049
Mailing Address - Fax:707-778-1702
Practice Address - Street 1:719 SOUTHPOINT BLVD
Practice Address - Street 2:STE B
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-1495
Practice Address - Country:US
Practice Address - Phone:707-778-8421
Practice Address - Fax:707-778-1702
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG52583207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G525830OtherBLUE SHIELD OF CALIFORNIA
CA00G525830Medicaid
CA060014838OtherRAILROAD MEDICARE
CA00G525830Medicaid
CA00G525830OtherBLUE SHIELD OF CALIFORNIA