Provider Demographics
NPI:1316993611
Name:SUTTER GOULD MEDICAL FOUNDATION
Entity type:Organization
Organization Name:SUTTER GOULD MEDICAL FOUNDATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:MITNICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-521-6097
Mailing Address - Street 1:600 COFFEE RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-4201
Mailing Address - Country:US
Mailing Address - Phone:209-521-6097
Mailing Address - Fax:209-521-4081
Practice Address - Street 1:3846 CASCADIA AVE S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98118-1129
Practice Address - Country:US
Practice Address - Phone:209-521-6097
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD135109Medicare PIN
AZZ122068Medicare PIN
WAG8873420Medicare PIN
VAC10491Medicare PIN
DC203026Medicare PIN
HIDM348AMedicare PIN
TN103G701593Medicare PIN
IN256620Medicare PIN
NVDL491AMedicare PIN
NJ124665Medicare PIN
COCOB4176Medicare PIN
AZZ121915Medicare PIN