Basic Information
| Provider Information | |||||||||
| NPI: | 1518973379 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHORE REHABILITATION INSTITUTE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 80 JAMES ST | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | EDISON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088203938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7326321571 | ||||||||
| FaxNumber: | 7326321676 | ||||||||
| Practice Location | |||||||||
| Address1: | 425 JACK MARTIN BLVD | ||||||||
| Address2: | |||||||||
| City: | BRICK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 087247732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7328364506 | ||||||||
| FaxNumber: | 7326321676 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 09/11/2008 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | SR VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7323217747 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283X00000X | 22219 | NJ | Y | Hospitals | Rehabilitation Hospital |
ID Information
| ID | Type | State | Issuer | Description | 6512909 | 05 | NJ | MEDICAID |