Provider Demographics
NPI:1245492321
Name:NORTHERN CALIFORNIA MEDICAL ASSOC INC
Entity type:Organization
Organization Name:NORTHERN CALIFORNIA MEDICAL ASSOC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF BUSINESS SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:DEWALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-525-6485
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:707-525-6485
Mailing Address - Fax:707-573-6918
Practice Address - Street 1:1701 4TH ST STE 100
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404
Practice Address - Country:US
Practice Address - Phone:707-578-1222
Practice Address - Fax:707-578-8348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-30
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGRE001460Medicaid
CAZZZ29088ZOtherBLUE SHIELD OF CALIFORNIA
CAGRE001460Medicaid
CA0367150002Medicare NSC