Provider Demographics
NPI:1265489850
Name:GRACE FAMILY MEDICAL GROUP
Entity Type:Organization
Organization Name:GRACE FAMILY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:S
Authorized Official - Last Name:SHIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-638-1347
Mailing Address - Street 1:2100 S EUCLID ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92802
Mailing Address - Country:US
Mailing Address - Phone:714-638-1347
Mailing Address - Fax:714-534-2098
Practice Address - Street 1:2100 S EUCLID ST
Practice Address - Street 2:SUITE 101
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92802
Practice Address - Country:US
Practice Address - Phone:714-638-1347
Practice Address - Fax:714-534-2098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA49058207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ29510ZOtherBLUE SHIELD
CA0251124Medicaid
=========OtherTAX ID
=========OtherTAX ID
CAW11568AMedicare ID - Type Unspecified
ZZZ29510ZOtherBLUE SHIELD