Provider Demographics
NPI:1003231341
Name:MERCED FACULTY ASSOCIATES MEDICAL GROUP, INCORPORATED
Entity Type:Organization
Organization Name:MERCED FACULTY ASSOCIATES MEDICAL GROUP, INCORPORATED
Other - Org Name:MFA G STREET
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-761-4555
Mailing Address - Street 1:PO BOX 3768
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95344-3768
Mailing Address - Country:US
Mailing Address - Phone:209-725-7149
Mailing Address - Fax:209-726-0259
Practice Address - Street 1:3393 G ST
Practice Address - Street 2:SUITE C
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95340-0964
Practice Address - Country:US
Practice Address - Phone:209-725-7149
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-24
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty