Provider Demographics
NPI:1649260126
Name:QUEEN OF THE VALLEY MEDICAL ASSOCIATION
Entity type:Organization
Organization Name:QUEEN OF THE VALLEY MEDICAL ASSOCIATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:SCARBOROUGH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-252-4411
Mailing Address - Street 1:1100 TRANCAS ST
Mailing Address - Street 2:SUITE 209
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558-2908
Mailing Address - Country:US
Mailing Address - Phone:707-252-4411
Mailing Address - Fax:707-251-1833
Practice Address - Street 1:1100 TRANCAS ST
Practice Address - Street 2:SUITE 209
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-2908
Practice Address - Country:US
Practice Address - Phone:707-252-4411
Practice Address - Fax:707-251-1860
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. JUDE'S HOSPITAL YORBA LINDA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-25
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA35569207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABH969Medicare PIN