NPIMap

Organization Active NPI

Redwood Pediatric Medical Group

  • Specialist
  • Fortuna, CA
National Provider Identifier
1164574083
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
SpecialistTaxonomy code 174400000X
License
G082256 Issued in CA
Legal business name
REDWOOD PEDIATRIC MEDICAL GROUP
Practice address
3305 Renner Dr
Fortuna, CA 95540-3119
Phone
(707) 725-9355
Fax
(707) 725-2426
NPI assigned
Jan 18, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Shalamar Ivey
Title
Billing Manager
Phone
(707) 725-9355

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
SpecialistGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 174400000X G082256 CA Primary

Addresses

Primary practice location

3305 Renner Dr
Fortuna, CA 95540-3119

Mailing address

3305 Renner Dr
Fortuna, CA 95540-3119

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20110105001209 CA Part A Provider - Rural Health Clinic 7416146584 Practice locations: Fortuna, CA

Rural health clinic certification: CCN 553836

Legal name
REDWOOD PEDIATRIC MEDICAL GROUP
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Aug 30, 1994
Last certification
Jul 18, 2017
Ownership / control type
1C
Organization structure
PartnershipProprietary
Enrollment address
3305 Renner Drive
Fortuna, CA 95540-3119

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
05D0613017Redwood Pediatric Medical Group3305 Renner Drive, Fortuna, CA 95540Certificate of waiverDec 31, 2026

National Provider Directory

National Provider Directory

Locations

3305 Renner Dr
Fortuna, CA 95540
Phone (707) 725-9355

Ownership & related parties

All disclosed owners & managing parties 4

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
James Killfoil Individual 5% Or Greater Direct Ownership Interest Jul 1, 1996 33.3%
General Partnership InterestOwner Jul 1, 1997 33.3%
Victoria Donahue Individual W-2 Managing Employee Aug 30, 1994
Evan Buxbaum Individual 5% Or Greater Direct Ownership Interest Sep 1, 2012 33.3%
General Partnership InterestOwner Sep 1, 2013 33.3%
Erika Rosenberg Individual 5% Or Greater Direct Ownership Interest Jun 1, 1996 33.3%
General Partnership InterestOwner Jun 1, 1997 33.3%

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

  • Evan Buxbaum, MD
    • Pediatrics Physician
    • Eastsound, WA
    • NPI 1174633069

    5% Or Greater Direct Ownership Interest, General Partnership Interest

    CMS ownership

Practitioners & affiliated clinicians

Practitioners 6

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1169078400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1164574083",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3305 RENNER DR",
            "city": "FORTUNA",
            "state": "CA",
            "postal_code": "955403119",
            "fax_number": "707-725-2426"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3305 RENNER DR",
            "city": "FORTUNA",
            "state": "CA",
            "postal_code": "955403119",
            "telephone_number": "707-725-9355",
            "fax_number": "707-725-2426"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "REDWOOD PEDIATRIC MEDICAL GROUP",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-18",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "IVEY",
        "authorized_official_first_name": "SHALAMAR",
        "authorized_official_title_or_position": "BILLING MANAGER",
        "authorized_official_telephone_number": "707-725-9355",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Specialist",
            "state": "CA",
            "license": "G082256",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Fortuna, CA

Sources for this page

Verify at the official NPI Registry.