Provider Demographics
NPI:1952555740
Name:SANTA ROSA SPORTS MEDICINE, INCORPORATED
Entity Type:Organization
Organization Name:SANTA ROSA SPORTS MEDICINE, INCORPORATED
Other - Org Name:SANTA ROSA SPORTS AND FAMILY MEDICINE
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TY
Authorized Official - Middle Name:PRESTON
Authorized Official - Last Name:AFFLECK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-546-9400
Mailing Address - Street 1:1255 N DUTTON AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-4663
Mailing Address - Country:US
Mailing Address - Phone:707-546-9400
Mailing Address - Fax:707-546-9464
Practice Address - Street 1:1255 N DUTTON AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4663
Practice Address - Country:US
Practice Address - Phone:707-546-9400
Practice Address - Fax:707-546-9464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-06
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG073843207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABG316Medicare PIN