Provider Demographics
NPI:1053820399
Name:FREDERICK C. SHAW & ASSOCIATES
Entity Type:Organization
Organization Name:FREDERICK C. SHAW & ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:FREDA
Authorized Official - Middle Name:A
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-722-2344
Mailing Address - Street 1:645 ERNEST W BARRETT PKWY NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-4922
Mailing Address - Country:US
Mailing Address - Phone:770-420-2268
Mailing Address - Fax:
Practice Address - Street 1:645 ERNEST W BARRETT PKWY NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-4922
Practice Address - Country:US
Practice Address - Phone:770-420-2268
Practice Address - Fax:770-825-9200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-28
Last Update Date:2017-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1535152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty