Provider Demographics
NPI:1538125059
Name:SHIRLEY M CHAN M D A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:SHIRLEY M CHAN M D A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:M
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-243-8431
Mailing Address - Street 1:PO BOX 80305
Mailing Address - Street 2:
Mailing Address - City:CITY OF INDUSTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91716-8305
Mailing Address - Country:US
Mailing Address - Phone:818-243-8431
Mailing Address - Fax:818-247-9239
Practice Address - Street 1:1505 WILSON TERRACE
Practice Address - Street 2:STE 350
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4072
Practice Address - Country:US
Practice Address - Phone:818-243-8431
Practice Address - Fax:818-247-9239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-24
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG58168207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G581680Medicaid
CAE73295Medicare UPIN
CA00G581680Medicaid