Basic Information
| Provider Information | |||||||||
| NPI: | 1275579765 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHORELINE ORTHOPAEDIC & SPORTS MEDICINE CLINIC,PLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | N . 370 120TH AVE | ||||||||
| Address2: | |||||||||
| City: | HOLLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494242196 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163965855 | ||||||||
| FaxNumber: | 6163965720 | ||||||||
| Practice Location | |||||||||
| Address1: | 370 120TH AVE | ||||||||
| Address2: | |||||||||
| City: | HOLLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494242196 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163965855 | ||||||||
| FaxNumber: | 6163965720 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 08/24/2016 | ||||||||
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| AuthorizedOfficialLastName: | SCHILDHOUSE | ||||||||
| AuthorizedOfficialFirstName: | TRICIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6163965855 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0106X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.