Provider Demographics
NPI:1912408691
Name:NORTHERN CALIFORNIA MEDICAL ASSOC
Entity Type:Organization
Organization Name:NORTHERN CALIFORNIA MEDICAL ASSOC
Other - Org Name:NORTHERN CALIFORNIA MEDICAL ASSOCIATES, INC.
Other - Org Type:Doing Business As
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 STE 200
Mailing Address - Street 2:
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 1:2315 DEAN ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-3208
Practice Address - Country:US
Practice Address - Phone:707-525-3786
Practice Address - Fax:707-525-3791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-27
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty