Basic Information
| Provider Information | |||||||||
| NPI: | 1588803373 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUTTER GOULD MEDICAL FOUNDATION | ||||||||
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| OtherOrganizationName: | BRIGGSMORE SPECIALTY CENTER AMBULATORY SURGICAL 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: | 1409 E BRIGGSMORE AVE | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953552707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095241211 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2009 | ||||||||
| LastUpdateDate: | 08/04/2010 | ||||||||
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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: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0800X | 10022 | CA | N | Ambulatory Health Care Facilities | Clinic/Center | Endoscopy | 261QA1903X | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.