Provider Demographics
NPI:1255884938
Name:SHAW MEDICAL GROUP LLC
Entity type:Organization
Organization Name:SHAW MEDICAL GROUP LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARMENCITA
Authorized Official - Middle Name:E
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:321-593-6999
Mailing Address - Street 1:947 BAREFOOT BLVD
Mailing Address - Street 2:
Mailing Address - City:BAREFOOT BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32976-7101
Mailing Address - Country:US
Mailing Address - Phone:321-593-6999
Mailing Address - Fax:321-327-2262
Practice Address - Street 1:947 BAREFOOT BLVD
Practice Address - Street 2:
Practice Address - City:BAREFOOT BAY
Practice Address - State:FL
Practice Address - Zip Code:32976-7101
Practice Address - Country:US
Practice Address - Phone:321-593-6999
Practice Address - Fax:321-327-2262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-28
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019884700Medicaid
FL019879900Medicaid