Provider Demographics
NPI:1972683654
Name:SANTA ROSA GASTROENTEROLOGY MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:SANTA ROSA GASTROENTEROLOGY MEDICAL ASSOCIATES
Other - Org Name:SRGMA INC
Other - Org Type:Other Name
Authorized Official - Title/Position:MD DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LOGAN
Authorized Official - Last Name:FAUST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-544-5093
Mailing Address - Street 1:1210 SONOMA AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405
Mailing Address - Country:US
Mailing Address - Phone:707-544-5093
Mailing Address - Fax:707-528-8444
Practice Address - Street 1:1210 SONOMA AVE
Practice Address - Street 2:SUITE B
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405
Practice Address - Country:US
Practice Address - Phone:707-544-5093
Practice Address - Fax:707-528-8444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0101070Medicaid
ZZZ02782ZMedicare UPIN
CAZZZ02782ZMedicare PIN