Healthcare Provider Details

I. General information

NPI: 1275351561
Provider Name (Legal Business Name): SHAKER MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2024
Last Update Date: 11/06/2024
Certification Date: 11/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1752 E LUGONIA AVE STE 117-1027
REDLANDS CA
92374-2730
US

IV. Provider business mailing address

1752 E LUGONIA AVE STE 117-1027
REDLANDS CA
92374-2730
US

V. Phone/Fax

Practice location:
  • Phone: 951-977-1082
  • Fax:
Mailing address:
  • Phone: 951-977-1082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ELIZABETH S GENDY-SHAKER
Title or Position: PRESIDENT
Credential: MD
Phone: 951-977-1082