=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437606100
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHRISTIAN MEDICAL CENTRE, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2016
-----------------------------------------------------
Last Update Date | 09/09/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 897 PARKWAY AVE
-----------------------------------------------------
City | EWING
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08618-2305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-344-9009
-----------------------------------------------------
Fax | 856-997-9262
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 897 PARKWAY AVE
-----------------------------------------------------
City | EWING
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08618-2305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-344-9009
-----------------------------------------------------
Fax | 856-997-9262
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | WAYNE A SHAW
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 609-469-4673
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number | 25MA091266300
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------