MEDICARE: RANDALL G. SHUE D.O. INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	20A5142	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1770758187
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RANDALL G. SHUE D.O. INC.

Provider Business Mailing Address
First Line	:	4055 E OLYMPIC BLVD
Second Line	:	#210
City	:	LOS ANGELES
State	:	CA
Zip	:	90023-3345
Country	:	US
Telephone Number	:	323-268-3491
Fax Number	:

Provider Business Practice Location Address
First Line	:	4055 E OLYMPIC BLVD
Second Line	:	#210
City	:	LOS ANGELES
State	:	CA
Zip	:	90023-3345
Country	:	US
Telephone Number	:	323-268-3491
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. RANDALL G. SHUE
Credential	:	D.O.
Telephone Number	:	323-268-3491

Provider Enumeration Date	:	04/25/2008
Last Update Date	:	04/25/2008

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