Provider Demographics
NPI:1134139769
Name:SANTA ROSA MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:SANTA ROSA MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:EILERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-987-5041
Mailing Address - Street 1:3661 E. LAS POSAS RD
Mailing Address - Street 2:G162
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010
Mailing Address - Country:US
Mailing Address - Phone:805-987-5041
Mailing Address - Fax:805-987-6297
Practice Address - Street 1:3661 E. LAS POSAS RD
Practice Address - Street 2:G162
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010
Practice Address - Country:US
Practice Address - Phone:805-987-5041
Practice Address - Fax:805-987-6297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48615207R00000X
CAA61469207R00000X
CAG36258207RE0101X
CAG43738207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
Not Answered207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ16399ZOtherBLUE SHIELD
A49447Medicare UPIN
CAE86378Medicare UPIN
CAG90807Medicare UPIN
CAW10094Medicare ID - Type Unspecified
CAA46625Medicare UPIN