NPIMap

Organization Active NPI

Shine MMG Inc

Doing business as Shine MMG

  • Family Medicine Physician
  • Glendale, CA
National Provider Identifier
1053930248
Registry record updated Apr 8, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
SHINE MMG INC
Doing business as
Shine MMG
Practice address
450 N Brand Blvd Ste 625a
Glendale, CA 91203-2347
Phone
(818) 745-0070
Fax
(818) 745-0065
NPI assigned
Apr 8, 2020
Last updated
Apr 8, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 8, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Emil Golub
Title
Cfo
Phone
(424) 204-6004

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X Primary

Addresses

Primary practice location

450 N Brand Blvd Ste 625a
Glendale, CA 91203-2347

Mailing address

450 N Brand Blvd Ste 625a
Glendale, CA 91203-2347
Phone (818) 745-0070

Other names 1

  • Shine MMG Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20200505000514 CA Part B Supplier - Clinic/Group Practice 6103257282 Receives reassigned benefits from 32 practitioners
Practice locations: Glendale, CA

National Provider Directory

National Provider Directory

Locations

130 N Brand Blvd
Ste 204
Glendale, CA 91203
Phone (818) 570-9065

450 N Brand Blvd
Ste 625A
Glendale, CA 91203
Phone (818) 745-0070

Practitioners & affiliated clinicians

Practitioners 31

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 31

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1586304000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1586304000000",
    "number": "1053930248",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "450 N BRAND BLVD STE 625A",
            "city": "GLENDALE",
            "state": "CA",
            "postal_code": "912032347",
            "telephone_number": "818-745-0070",
            "fax_number": "818-745-0065"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "450 N BRAND BLVD STE 625A",
            "city": "GLENDALE",
            "state": "CA",
            "postal_code": "912032347",
            "telephone_number": "818-745-0070",
            "fax_number": "818-745-0065"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHINE MMG INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-04-08",
        "last_updated": "2020-04-08",
        "certification_date": "2020-04-08",
        "status": "A",
        "authorized_official_last_name": "GOLUB",
        "authorized_official_first_name": "EMIL",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "424-204-6004"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Shine MMG",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Glendale, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 8, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.