Provider Demographics
NPI:1639334436
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:PRESIDENT, SMGR
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:LEVENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DO
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 1:8465 OLD REDWOOD HWY
Practice Address - Street 2:SUITE 320
Practice Address - City:WINDSOR
Practice Address - State:CA
Practice Address - Zip Code:95492-8090
Practice Address - Country:US
Practice Address - Phone:707-521-8809
Practice Address - Fax:707-521-8835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-22
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ013170ZOtherBLUE SHIELD
CAGR0091420Medicaid
CAZZZ21969ZMedicare PIN