Provider Demographics
NPI:1417044801
Name:PETER J MARINCOVICH
Entity type:Organization
Organization Name:PETER J MARINCOVICH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER AUDIOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:JANSEN
Authorized Official - Last Name:MARINCOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD AUDIOLOGIST DISP
Authorized Official - Phone:707-523-4740
Mailing Address - Street 1:1111 SONOMA AVE
Mailing Address - Street 2:SUITE 316
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4819
Mailing Address - Country:US
Mailing Address - Phone:707-523-4740
Mailing Address - Fax:707-523-0231
Practice Address - Street 1:1111 SONOMA AVE
Practice Address - Street 2:SUITE 316
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4819
Practice Address - Country:US
Practice Address - Phone:707-523-4740
Practice Address - Fax:707-523-0231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU758231H00000X
CAHA1949237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA640002077OtherRRM
CAZZZ03361ZOtherBLUE SHIELD
CAAU0007580Medicaid
CAZZZ03362ZOtherBLUE SHIELD
CAZZZ03361ZOtherBLUE SHIELD