Provider Demographics
NPI:1538942842
Name:SUTTER BAY MEDICAL FOUNDATION
Entity type:Organization
Organization Name:SUTTER BAY MEDICAL FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MELODY
Authorized Official - Middle Name:
Authorized Official - Last Name:STATES
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:650-683-5032
Mailing Address - Street 1:701 E EL CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-2833
Mailing Address - Country:US
Mailing Address - Phone:408-203-3941
Mailing Address - Fax:
Practice Address - Street 1:393 BLOSSOM HILL RD STE 365
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95123-1659
Practice Address - Country:US
Practice Address - Phone:408-203-3941
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUTTER BAY MEDICAL FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-08-18
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical