Provider Demographics
NPI:1174925697
Name:SPINE AND NEUROSURGICAL TRAUMA ASSOCIATES OF NORTHERN CALIFORNIA
Entity type:Organization
Organization Name:SPINE AND NEUROSURGICAL TRAUMA ASSOCIATES OF NORTHERN CALIFORNIA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:GLICKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:707-799-5911
Mailing Address - Street 1:1275 4TH ST
Mailing Address - Street 2:PMB 646
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-4057
Mailing Address - Country:US
Mailing Address - Phone:707-799-5911
Mailing Address - Fax:
Practice Address - Street 1:4690 HOEN AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-7823
Practice Address - Country:US
Practice Address - Phone:707-799-5911
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-17
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA133052084V0102X, 207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular NeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3102403Medicaid