=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922245349
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHADY CANYON MEDICAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2009
-----------------------------------------------------
Last Update Date | 12/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15825 LAGUNA CANYON RD STE 104
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92618-2126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-585-9870
-----------------------------------------------------
Fax | 949-585-9331
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15825 LAGUNA CANYON RD STE 104
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92618-2126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-585-9870
-----------------------------------------------------
Fax | 949-585-9331
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD/OWNER
-----------------------------------------------------
Name | DR. ALBERT BEOMJIN CHANG
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 949-585-9870
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | A77997
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------