Basic Information
Provider Information | |||||||||
NPI: | 1538300660 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MERCED FACULTY ASSOCIATES MEDICAL GROUP INCORPORATED | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | EL PORTAL MEDICAL ONCOLOGY CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: |   | ||||||||
City: | MERCED | ||||||||
State: | CA | ||||||||
PostalCode: | 953400994 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2097263410 | ||||||||
FaxNumber: | 2097263371 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/19/2009 | ||||||||
LastUpdateDate: | 07/15/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SHAW | ||||||||
AuthorizedOfficialFirstName: | REBECCA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 2097231920 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QX0200X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Oncology |
ID Information
ID | Type | State | Issuer | Description | ZZZ57772Y | 01 | CA | BLUE SHIELD PIN | OTHER | 1538300660 | 05 | CA |   | MEDICAID |