Provider Demographics
NPI:1982791380
Name:REDWOOD REGIONAL MEDICAL GROUP
Entity Type:Organization
Organization Name:REDWOOD REGIONAL MEDICAL GROUP
Other - Org Name:ADVANCED IMAGING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HELEN
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-546-4062
Mailing Address - Street 1:652 PETALUMA AVE STE I
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-4266
Mailing Address - Country:US
Mailing Address - Phone:707-829-2141
Mailing Address - Fax:707-829-2966
Practice Address - Street 1:652 PETALUMA AVE
Practice Address - Street 2:SUITE I
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-4256
Practice Address - Country:US
Practice Address - Phone:707-829-2141
Practice Address - Fax:707-829-2966
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REDWOOD REGIONAL MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-06
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Multi-Specialty
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiologyGroup - Multi-Specialty
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear RadiologyGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0049209Medicaid
CAGR0049209Medicaid