Basic Information
| Provider Information | |||||||||
| NPI: | 1174552632 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERCED FACULTY ASSOCIATES MEDICAL GROUP INCORPORATED | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EL PORTAL ENDOSURGERY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3768 | ||||||||
| Address2: | |||||||||
| City: | MERCED | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953443768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2097257149 | ||||||||
| FaxNumber: | 2097260259 | ||||||||
| Practice Location | |||||||||
| Address1: | 3365 G ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | MERCED | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953400994 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2092051086 | ||||||||
| FaxNumber: | 2093832811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 07/21/2014 | ||||||||
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| AuthorizedOfficialLastName: | SHAW | ||||||||
| AuthorizedOfficialFirstName: | REBECCA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2097231920 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | N | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical | 261QE0800X | Y | Ambulatory Health Care Facilities | Clinic/Center | Endoscopy |
ID Information
| ID | Type | State | Issuer | Description | ZZZH2406Z | 01 | CA | BLUE SHIELD PIN | OTHER |