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General NPI Number Information
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NPI Number | 1376098343
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Entity Type | Organization
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Legal Business Name | SHAW MEDICAL GROUP PROFESSIONAL CORPORATION
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Dates
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Enumeration Date | 08/19/2016
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Last Update Date | 08/19/2016
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Provider Practice Location Address
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Address Line | 1001 W CARSON ST SUITE I
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City | TORRANCE
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State | CA
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Zip | 90502-2051
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Country | US
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Telephone | 310-533-9233
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Fax | 310-533-9292
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Provider Business Mailing Address
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Address Line | 1001 W CARSON ST SUITE I
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City | TORRANCE
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State | CA
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Zip | 90502-2051
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Country | US
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Telephone | 310-533-9233
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Fax | 310-533-9292
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Authorized Official
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Title or Position | PRESIDENT / MEDICAL DIRECTOR
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Name | DR. BETSY ALCID SHAW
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Credential | MD
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Telephone | 310-702-7699
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 714688
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License Number State | CA
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