1205034964 NPI number — MERCED FACULTY ASSOCIATES MEDICAL GROUP INCORPORATED

Table of content: (NPI 1205034964)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205034964 NPI number — MERCED FACULTY ASSOCIATES MEDICAL GROUP INCORPORATED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MERCED FACULTY ASSOCIATES MEDICAL GROUP INCORPORATED
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205034964
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3768
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERCED
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95344-3768
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-725-7149
Provider Business Mailing Address Fax Number:
209-726-0259

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1675 SHAFFER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATWATER
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95301-4456
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-383-5500
Provider Business Practice Location Address Fax Number:
209-383-6910
Provider Enumeration Date:
07/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SHAW
Authorized Official First Name:
REBECCA
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
209-725-7149

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ZZZ61444Z . This is a "BLUE SHIELD GROUP NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: CS1342 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0041484 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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