0001937800-22-000001.txt : 20220712 0001937800-22-000001.hdr.sgml : 20220712 20220712172456 ACCESSION NUMBER: 0001937800-22-000001 CONFORMED SUBMISSION TYPE: D PUBLIC DOCUMENT COUNT: 1 ITEM INFORMATION: 06b FILED AS OF DATE: 20220712 DATE AS OF CHANGE: 20220712 EFFECTIVENESS DATE: 20220712 FILER: COMPANY DATA: COMPANY CONFORMED NAME: PROVIDENCE MEDICAL GROUP, NORTHERN CALIFORNIA CENTRAL INDEX KEY: 0001937800 IRS NUMBER: 881779768 STATE OF INCORPORATION: CA FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: D SEC ACT: 1933 Act SEC FILE NUMBER: 021-452057 FILM NUMBER: 221079752 BUSINESS ADDRESS: STREET 1: 185 SOTOYOME STREET CITY: SANTA ROSA STATE: CA ZIP: 95405 BUSINESS PHONE: 707-387-3927 MAIL ADDRESS: STREET 1: 185 SOTOYOME STREET CITY: SANTA ROSA STATE: CA ZIP: 95405 D 1 primary_doc.xml X0708 D LIVE 0001937800 PROVIDENCE MEDICAL GROUP, NORTHERN CALIFORNIA 185 SOTOYOME STREET SANTA ROSA CA CALIFORNIA 95405 707-387-3927 CALIFORNIA None None Corporation true 2022 Jeannette B. Currie, M.D. 185 Sotoyome Street Santa Rosa CA CALIFORNIA 95405 Executive Officer Director Abhijit Adhye, M.D. 185 Sotoyome Street Santa Rosa CA CALIFORNIA 95405 Executive Officer Director Gregory Houghton, M.D. 185 Sotoyome Street Santa Rosa CA CALIFORNIA 95405 Executive Officer Director Mark Pardoe, M.D. 185 Sotoyome Street Santa Rosa CA CALIFORNIA 95405 Executive Officer Director Leo Leer, M.D. 185 Sotoyome Street Santa Rosa CA CALIFORNIA 95405 Executive Officer Director John Aryanpur, M.D. 185 Sotoyome Street Santa Rosa CA CALIFORNIA 95405 Executive Officer Erik McGoldrick, M.D. 185 Sotoyome Street Santa Rosa CA CALIFORNIA 95405 Director Susana Gonzalez, M.D. 185 Sotoyome Street Santa Rosa CA CALIFORNIA 95405 Director Deborah Britt, M.D. 185 Sotoyome Street Santa Rosa CA CALIFORNIA 95405 Director Paul Shen, M.D. 185 Sotoyome Street Santa Rosa CA CALIFORNIA 95405 Director Daniel Gilbert, D.O. 185 Sotoyome Street Santa Rosa CA CALIFORNIA 95405 Director Avinash Ramchandani, M.D. 185 Sotoyome Street Santa Rosa CA CALIFORNIA 95405 Director Hospitals and Physicians Decline to Disclose 06b false 2022-07-01 false true false 1500 246000 246000 0 false 164 0 0 0 false PROVIDENCE MEDICAL GROUP, NORTHERN CALIFORNIA Jeannette B. Currie, M.D. Jeannette B. Currie, M.D. President 2022-07-12