Provider Demographics
NPI:1104963834
Name:NEUROSURGICAL TRAUMA SERVICES
Entity type:Organization
Organization Name:NEUROSURGICAL TRAUMA SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BAHRAM
Authorized Official - Middle Name:
Authorized Official - Last Name:CHEHRAZI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-771-3393
Mailing Address - Street 1:PO BOX 2600
Mailing Address - Street 2:
Mailing Address - City:GRANITE BAY
Mailing Address - State:CA
Mailing Address - Zip Code:95746-2600
Mailing Address - Country:US
Mailing Address - Phone:916-771-3393
Mailing Address - Fax:
Practice Address - Street 1:1301 SECRET RAVINE PKWY
Practice Address - Street 2:STE 200
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3096
Practice Address - Country:US
Practice Address - Phone:916-771-3393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2009-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0070590Medicaid
CAZZZ49984ZOtherBLUE SHIELD GROUP ID
CAZZZ00973ZMedicare ID - Type UnspecifiedMEDICARE GROUP NUMBER