Basic Information
| Provider Information | |||||||||
| NPI: | 1497763239 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SMART SISKIYOU MEDICAL ARTS, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 15546 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958521546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8776932787 | ||||||||
| FaxNumber: | 8585057101 | ||||||||
| Practice Location | |||||||||
| Address1: | 444 BRUCE ST | ||||||||
| Address2: | |||||||||
| City: | YREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960973450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5308424121 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 01/11/2011 | ||||||||
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| AuthorizedOfficialLastName: | PEREIRA | ||||||||
| AuthorizedOfficialFirstName: | GABRIEL | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5305213500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | A45016 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 611685800 | 01 | CA | DOL | OTHER | 6330337 | 05 | CA | MEDICAID | DF2250 | 01 | CA | RAILROAD MEDICARE | OTHER | A001 | 01 | CA | TRICARE | OTHER |