Provider Demographics
NPI:1902976236
Name:EL ROSE MEDICAL GROUP
Entity Type:Organization
Organization Name:EL ROSE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:SISLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-763-9491
Mailing Address - Street 1:24 WEST EL ROSE AVE
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952
Mailing Address - Country:US
Mailing Address - Phone:707-763-9891
Mailing Address - Fax:707-763-9896
Practice Address - Street 1:24 WEST EL ROSE AVE
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952
Practice Address - Country:US
Practice Address - Phone:707-763-9891
Practice Address - Fax:707-763-9896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C26495OtherSTATE LICENSE #
CP6140OtherRAILROAD MEDICARE
ZZZ75987ZOtherMEDI CAL
AROSE0543OtherBLUE CROSS BLUE SHIELD
C17753OtherSTATE LICENSE #
G21106OtherSTATE LICENSE #
ZZZ75987ZOtherMEDI CAL GRP #
ZZZ75987ZOtherMEDI CAL GRP #
CP6140OtherRAILROAD MEDICARE
AROSE0543OtherBLUE CROSS BLUE SHIELD
A33142Medicare UPIN
A31088Medicare UPIN
ZZZ75987ZMedicare ID - Type UnspecifiedIND #