Provider Demographics
NPI:1801914163
Name:NORTH BAY NEUROSURGICAL ASSOCIATES MEDICAL GROUP
Entity type:Organization
Organization Name:NORTH BAY NEUROSURGICAL ASSOCIATES MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENTI
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:T
Authorized Official - Last Name:HUNSTOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-523-1873
Mailing Address - Street 1:525 DOYLE PARK DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4516
Mailing Address - Country:US
Mailing Address - Phone:707-525-1873
Mailing Address - Fax:707-523-0119
Practice Address - Street 1:525 DOYLE PARK DR
Practice Address - Street 2:SUITE 102
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4516
Practice Address - Country:US
Practice Address - Phone:707-525-1873
Practice Address - Fax:707-523-0119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC40718207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0030300Medicaid
CAGR0030300Medicaid
CAA37434Medicare UPIN
CAG19370Medicare UPIN
CAA46235Medicare UPIN
CA00C407180Medicare ID - Type Unspecified
CA00G757750Medicare ID - Type Unspecified