Provider Demographics
NPI:1801992128
Name:WOMENS OB/GYN MEDICAL GROUP
Entity type:Organization
Organization Name:WOMENS OB/GYN MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DONA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROMANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-579-1102
Mailing Address - Street 1:500 DOYLE PARK DRIVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-9559
Mailing Address - Country:US
Mailing Address - Phone:707-579-1102
Mailing Address - Fax:707-579-1386
Practice Address - Street 1:500 DOYLE PARK DRIVE
Practice Address - Street 2:SUITE 103
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-9559
Practice Address - Country:US
Practice Address - Phone:707-579-1102
Practice Address - Fax:707-579-1386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0088200Medicaid
CAZZZ18400ZMedicare ID - Type Unspecified