Basic Information
| Provider Information | |||||||||
| NPI: | 1174570964 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUTTER GOULD MEDICAL FOUNDATION | ||||||||
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| OtherOrganizationName: | FAIRMONT AVE CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 COFFEE RD | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953554201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095241211 | ||||||||
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| Practice Location | |||||||||
| Address1: | 999 S FAIRMONT AVE | ||||||||
| Address2: | #130/135 | ||||||||
| City: | LODI | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952405100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093662001 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 05/06/2010 | ||||||||
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| AuthorizedOfficialLastName: | MITNICK | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2095216097 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.