Provider Demographics
NPI:1205034964
Name:MERCED FACULTY ASSOCIATES MEDICAL GROUP INCORPORATED
Entity Type:Organization
Organization Name:MERCED FACULTY ASSOCIATES MEDICAL GROUP INCORPORATED
Other - Org Name:MFA ATWATER
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:209-725-7149
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 1:1675 SHAFFER RD
Practice Address - Street 2:
Practice Address - City:ATWATER
Practice Address - State:CA
Practice Address - Zip Code:95301-4456
Practice Address - Country:US
Practice Address - Phone:209-383-5500
Practice Address - Fax:209-383-6910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-04
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ61444ZOtherBLUE SHIELD GROUP NUMBER
GACS1342OtherRAILROAD MEDICARE
CAGR0041484Medicaid
CAZZZ18707ZMedicare PIN