Provider Demographics
NPI:1538300660
Name:MERCED FACULTY ASSOCIATES MEDICAL GROUP INCORPORATED
Entity Type:Organization
Organization Name:MERCED FACULTY ASSOCIATES MEDICAL GROUP INCORPORATED
Other - Org Name:EL PORTAL MEDICAL ONCOLOGY CENTER
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:209-723-1920
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 1:3365 G ST
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95340-0994
Practice Address - Country:US
Practice Address - Phone:209-726-3410
Practice Address - Fax:209-726-3371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-19
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0200XAmbulatory Health Care FacilitiesClinic/CenterOncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ57772YOtherBLUE SHIELD PIN
CA1538300660Medicaid