Basic Information
| Provider Information | |||||||||
| NPI: | 1104814904 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHINBAUM | ||||||||
| FirstName: | LAWRENCE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 SEASIDE AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | MILFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064604603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037831831 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 300 SEASIDE AVE | ||||||||
| Address2: | |||||||||
| City: | MILFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064604603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2038764178 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2005 | ||||||||
| LastUpdateDate: | 10/20/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 040727 | CT | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 174400000X | 040727 | CT | N | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 001407271 | 05 | CT | MEDICAID |