Healthcare Provider Details

I. General information

NPI: 1780882522
Provider Name (Legal Business Name): MERCED FACULTY ASSOCIATES MEDICAL GROUP INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 07/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

378 W OLIVE AVE STE C
MERCED CA
95348-3137
US

IV. Provider business mailing address

PO BOX 3768
MERCED CA
95344-3768
US

V. Phone/Fax

Practice location:
  • Phone: 209-384-3198
  • Fax: 209-725-1603
Mailing address:
  • Phone: 209-725-7149
  • Fax: 209-726-0259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: REBECCA SHAW
Title or Position: CEO
Credential:
Phone: 209-723-1920