MEDICARE: SHIRLEY M CHAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	G58168	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1609830348
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHIRLEY M CHAN

Provider Business Mailing Address
First Line	:	PO BOX 80305
Second Line	:
City	:	CITY OF INDUSTRY
State	:	CA
Zip	:	91716-8305
Country	:	US
Telephone Number	:	818-243-8431
Fax Number	:	818-247-9239

Provider Business Practice Location Address
First Line	:	1505 WILSON TERRACE
Second Line	:	SUITE 350
City	:	GLENDALE
State	:	CA
Zip	:	91206-4072
Country	:	US
Telephone Number	:	818-243-8431
Fax Number	:	818-247-9239

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/12/2006
Last Update Date	:	06/27/2011

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Directions to “ SHIRLEY M CHAN ” Practice Location

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