Provider Demographics
NPI:1982798096
Name:SUTTER MEDICAL GROUP OF THE REDWOODS
Entity Type:Organization
Organization Name:SUTTER MEDICAL GROUP OF THE REDWOODS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:E
Authorized Official - Last Name:ROCKSTROH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-521-8809
Mailing Address - Street 1:3883 AIRWAY DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-1670
Mailing Address - Country:US
Mailing Address - Phone:707-521-8809
Mailing Address - Fax:707-521-8835
Practice Address - Street 1:3315 CHANATE RD
Practice Address - Street 2:SUITE 1C
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-1736
Practice Address - Country:US
Practice Address - Phone:707-571-2486
Practice Address - Fax:707-575-1872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207Q00000X, 207RE0101X, 207RG0100X, 208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0005542AMedicaid
CAGR0005542AMedicaid