Provider Demographics
NPI:1982648580
Name:SUTTER GOULD MEDICAL FOUNDATION
Entity Type:Organization
Organization Name:SUTTER GOULD MEDICAL FOUNDATION
Other - Org Name:KETTLEMAN CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:MITNICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-521-6097
Mailing Address - Street 1:600 COFFEE RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-4201
Mailing Address - Country:US
Mailing Address - Phone:209-524-1211
Mailing Address - Fax:
Practice Address - Street 1:1335 S FAIRMONT AVE
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-5520
Practice Address - Country:US
Practice Address - Phone:209-366-2007
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ20685ZMedicare ID - Type UnspecifiedMEDICARE NUMBER
CA0586060022Medicare NSC