Basic Information
| Provider Information | |||||||||
| NPI: | 1477513273 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHORE HEALTH SYSTEM, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DIAGNOSTIC AND IMAGING CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 219 S WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | EASTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216012913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108221000 | ||||||||
| FaxNumber: | 4107703836 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 MARTIN CT | ||||||||
| Address2: | |||||||||
| City: | EASTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216013833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108207778 | ||||||||
| FaxNumber: | 4108208862 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2006 | ||||||||
| LastUpdateDate: | 09/29/2022 | ||||||||
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| AuthorizedOfficialLastName: | KOZEL | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 4108221000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 09/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.