Healthcare Provider Details

I. General information

NPI: 1174552632
Provider Name (Legal Business Name): MERCED FACULTY ASSOCIATES MEDICAL GROUP INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 07/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3365 G ST SUITE 101
MERCED CA
95340-0994
US

IV. Provider business mailing address

PO BOX 3768
MERCED CA
95344-3768
US

V. Phone/Fax

Practice location:
  • Phone: 209-205-1086
  • Fax: 209-383-2811
Mailing address:
  • Phone: 209-725-7149
  • Fax: 209-726-0259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License Number
License Number State

VIII. Authorized Official

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