Provider Demographics
NPI:1376098343
Name:SHAW MEDICAL GROUP PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:SHAW MEDICAL GROUP PROFESSIONAL CORPORATION
Other - Org Name:REGAL FAMILY PRACTICE MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT / MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BETSY
Authorized Official - Middle Name:ALCID
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-702-7699
Mailing Address - Street 1:1001 W CARSON ST
Mailing Address - Street 2:SUITE I
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90502-2051
Mailing Address - Country:US
Mailing Address - Phone:310-533-9233
Mailing Address - Fax:310-533-9292
Practice Address - Street 1:1001 W CARSON ST
Practice Address - Street 2:SUITE I
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-2051
Practice Address - Country:US
Practice Address - Phone:310-533-9233
Practice Address - Fax:310-533-9292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-19
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA714688261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center