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Organization
SANTA ROSA ORTHOPAEDIC MEDICAL GROUP, INC.
Active
Organization
SANTA ROSA ORTHOPAEDIC MEDICAL GROUP, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
EVANGELINE VLACOS (CONTRACTING CREDENTIALING ASSOCIATE)
(510) 387-2193
Entity
Organization
Contact information
Practice address
1701 4TH ST STE 200, SANTA ROSA, CA 95404-3661
(707) 546-1922
(707) 528-1602
Mailing address
1701 4TH ST STE 200, SANTA ROSA, CA 95404-3661
(707) 546-1922
(707) 528-1602
Taxonomy
Speciality
Code
Description
License number
State
207X00000X
Orthopaedic Surgery Physician
Primary
—
NULL
207X00000X
Orthopaedic Surgery Physician
Primary
—
—
207XS0106X
Orthopaedic Hand Surgery Physician
—
NULL
207XS0106X
Orthopaedic Hand Surgery Physician
—
—
207XX0004X
Orthopaedic Foot and Ankle Surgery Physician
—
NULL
207XX0004X
Orthopaedic Foot and Ankle Surgery Physician
—
—
207XX0005X
Sports Medicine (Orthopaedic Surgery) Physician
—
NULL
207XX0005X
Sports Medicine (Orthopaedic Surgery) Physician
—
—
207XX0801X
Orthopaedic Trauma Physician
—
NULL
207XX0801X
Orthopaedic Trauma Physician
—
—
208100000X
Physical Medicine & Rehabilitation Physician
—
NULL
208100000X
Physical Medicine & Rehabilitation Physician
—
—
225100000X
Physical Therapist
—
NULL
225100000X
Physical Therapist
—
—
225XH1200X
Hand Occupational Therapist
—
NULL
225XH1200X
Hand Occupational Therapist
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0166366
DEPT OF LABOR WASH STATE
CA
01
—
1518907336
NPI
—
01
—
379618500
US DEPT OF LABOR (OWCP)
CA
05
—
GR0012520
—
CA
01
—
ZZZ92332Z
BLUE SHIELD GRP # 1405
CA
Enumeration date
06/08/2006
Last updated
05/20/2026
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