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Organization
PACIFIC REDWOOD MEDICAL GROUP INC
Active
Organization
PACIFIC REDWOOD MEDICAL GROUP INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. GARY W FAUSONE MD (PRESIDENT)
(707) 462-7900
Entity
Organization
Contact information
Practice address
275 HOSPITAL DR, UKIAH, CA 95482
(707) 462-7900
(707) 462-7947
Mailing address
PO BOX 2800, UKIAH, CA 95482-2800
(707) 462-7900
(707) 462-7947
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
—
—
207Q00000X
Family Medicine Physician
—
—
207R00000X
Internal Medicine Physician
—
—
208000000X
Pediatrics Physician
—
—
2080P0204X
Pediatric Emergency Medicine (Pediatrics) Physician
—
—
2083P0500X
Preventive Medicine/Occupational Environmental Medicine Physician
—
—
2083X0100X
Occupational Medicine Physician
—
—
208M00000X
Hospitalist Physician
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
17165692005
STATE COMPENSATION INS
CA
01
—
352149100
DOL (DEPT OF LABOR)
—
05
—
GR0093400
—
CA
01
—
ZZZ06060Z
BLUE SHIELD
CA
Enumeration date
09/09/2005
Last updated
07/31/2018
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