Provider Demographics
NPI:1881068443
Name:FMCPS SANTA ROSA LLC
Entity type:Organization
Organization Name:FMCPS SANTA ROSA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE VP
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-639-7185
Mailing Address - Street 1:3820 W HAPPY VALLEY RD
Mailing Address - Street 2:SUITE 141-120
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85310-3289
Mailing Address - Country:US
Mailing Address - Phone:844-540-8736
Mailing Address - Fax:602-798-8267
Practice Address - Street 1:435 DOYLE PARK DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4515
Practice Address - Country:US
Practice Address - Phone:707-527-9510
Practice Address - Fax:602-798-8267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-19
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty