Basic Information
| Provider Information | |||||||||
| NPI: | 1497750798 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHORELINE MEDICAL ASSOCIATES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1353 BOSTON POST RD | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064433445 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1353 BOSTON POST RD | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064433445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032454933 | ||||||||
| FaxNumber: | 2032454399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2005 | ||||||||
| LastUpdateDate: | 09/16/2015 | ||||||||
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| AuthorizedOfficialLastName: | SWENSON | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 2032454933 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 006159 | CT | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 001222280 | 05 | CT | MEDICAID | 001378422 | 05 | CT | MEDICAID | 001421916 | 05 | CT | MEDICAID |