Provider Demographics
NPI:1245348820
Name:PRIMARY CARE ASSOCIATES OF THE REDWOOD EMPIRE MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:PRIMARY CARE ASSOCIATES OF THE REDWOOD EMPIRE MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LYMAN
Authorized Official - Middle Name:BOWEN
Authorized Official - Last Name:GREAVES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-545-1300
Mailing Address - Street 1:500 DOYLE PARK DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4558
Mailing Address - Country:US
Mailing Address - Phone:707-545-1300
Mailing Address - Fax:707-303-8304
Practice Address - Street 1:500 DOYLE PARK DR
Practice Address - Street 2:SUITE 200
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4558
Practice Address - Country:US
Practice Address - Phone:707-545-1300
Practice Address - Fax:707-303-8304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA208000000X, 208M00000X, 133V00000X, 363LF0000X, 363LP0200X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0061380Medicaid
CAGR0061383Medicaid
CAGR0061381Medicaid
CAGR0061382Medicaid
CAGR0061382Medicaid
CAGR0061380Medicaid
CAZZZ42777ZMedicare PIN