Provider Demographics
NPI:1972704542
Name:SUTTER MEDICAL FOUNDATION
Entity Type:Organization
Organization Name:SUTTER MEDICAL FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-473-4531
Mailing Address - Street 1:15620 HEALDSBURG AVE
Mailing Address - Street 2:
Mailing Address - City:HEALDSBURG
Mailing Address - State:CA
Mailing Address - Zip Code:95448-9617
Mailing Address - Country:US
Mailing Address - Phone:707-473-4531
Mailing Address - Fax:707-473-4559
Practice Address - Street 1:3536 MENDOCINO AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-3634
Practice Address - Country:US
Practice Address - Phone:707-571-1280
Practice Address - Fax:707-578-5849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207Q00000X, 207R00000X, 207RE0101X, 207V00000X, 208000000X, 2080N0001X, 208600000X, 2086S0129X, 291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
Not Answered207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Not Answered2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Multi-Specialty
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Not Answered2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Not Answered291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty