Provider Demographics
NPI:1922245349
Name:SHADY CANYON MEDICAL GROUP
Entity Type:Organization
Organization Name:SHADY CANYON MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:BEOMJIN
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-375-8958
Mailing Address - Street 1:16300 SAND CANYON AVE
Mailing Address - Street 2:SUITE 901
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-3711
Mailing Address - Country:US
Mailing Address - Phone:951-375-8958
Mailing Address - Fax:949-453-8601
Practice Address - Street 1:16300 SAND CANYON AVE
Practice Address - Street 2:SUITE 901
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3711
Practice Address - Country:US
Practice Address - Phone:951-375-8958
Practice Address - Fax:949-453-8601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-08
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA77997207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty