Basic Information
| Provider Information | |||||||||
| NPI: | 1649501073 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHORE HEALTH SYSTEM, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SHORE HEALTH SYSTEM SURGERY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 219 S WASHINGTON STREET | ||||||||
| Address2: | |||||||||
| City: | EASTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216012913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108221000 | ||||||||
| FaxNumber: | 4108227834 | ||||||||
| Practice Location | |||||||||
| Address1: | 6 CAULK LANE | ||||||||
| Address2: | |||||||||
| City: | EASTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216013854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108225559 | ||||||||
| FaxNumber: | 4108228238 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2010 | ||||||||
| LastUpdateDate: | 03/01/2018 | ||||||||
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| AuthorizedOfficialLastName: | KOZEL | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 4108221000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 000305100 | 05 | MD | MEDICAID |