Provider Demographics
NPI:1922024736
Name:SHALOM MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:SHALOM MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-563-1997
Mailing Address - Street 1:1175 N EUCLID ST
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-1938
Mailing Address - Country:US
Mailing Address - Phone:714-563-1997
Mailing Address - Fax:
Practice Address - Street 1:1175 N EUCLID ST
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-1938
Practice Address - Country:US
Practice Address - Phone:714-563-1997
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA60371208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty