Healthcare Provider Details

I. General information

NPI: 1255884938
Provider Name (Legal Business Name): SHAW MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2016
Last Update Date: 05/25/2023
Certification Date: 05/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

947 BAREFOOT BLVD
BAREFOOT BAY FL
32976-7101
US

IV. Provider business mailing address

947 BAREFOOT BLVD
BAREFOOT BAY FL
32976-7101
US

V. Phone/Fax

Practice location:
  • Phone: 321-593-6999
  • Fax: 321-327-2262
Mailing address:
  • Phone: 321-593-6999
  • Fax: 321-327-2262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. CARMENCITA E SHAW
Title or Position: PROVIDER
Credential: DNP
Phone: 321-593-6999