Provider Demographics
NPI:1780736736
Name:NORTHBAY HEALTHCARE GROUP
Entity type:Organization
Organization Name:NORTHBAY HEALTHCARE GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AVP, MANAGED CARE SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:JAYE LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:BONHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-646-3289
Mailing Address - Street 1:1200 B GALE WILSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-3552
Mailing Address - Country:US
Mailing Address - Phone:707-646-3401
Mailing Address - Fax:707-646-4803
Practice Address - Street 1:416 NAPA JUNCTION RD
Practice Address - Street 2:
Practice Address - City:AMERICAN CANYON
Practice Address - State:CA
Practice Address - Zip Code:94503-1281
Practice Address - Country:US
Practice Address - Phone:707-646-4000
Practice Address - Fax:707-646-4001
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHBAY HEALTHCARE GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-18
Last Update Date:2025-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X, 261QU0200X, 261QP2300X
CA110000093282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA110000093OtherDHS LICENSE
CAGR0093200OtherMEDI-CAL PHYSICIAN GROUP
CAZZZ37432ZMedicare PIN
CAGR0093200OtherMEDI-CAL PHYSICIAN GROUP