Provider Demographics
NPI:1033100854
Name:SONORA COMMUNITY HOSPITAL
Entity type:Organization
Organization Name:SONORA COMMUNITY HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:D
Authorized Official - Last Name:JAHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-536-5011
Mailing Address - Street 1:14542 LOLLY LN
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-9226
Mailing Address - Country:US
Mailing Address - Phone:209-536-3900
Mailing Address - Fax:209-533-7696
Practice Address - Street 1:19747 GREENLEY RD
Practice Address - Street 2:SUITE S-2
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-5998
Practice Address - Country:US
Practice Address - Phone:209-536-2665
Practice Address - Fax:209-533-7696
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SONORA COMMUNITY HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-01
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA030000094207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ52953ZOtherBLUE CROSS/BLUE SHIELD
CA050335Medicare PIN
CAZZZ01042ZMedicare PIN
CA050335Medicare Oscar/Certification
CACU0092Medicare PIN