Basic Information
| Provider Information | |||||||||
| NPI: | 1669431219 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHORE HEALTH SYSTEM, INC | ||||||||
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| OtherOrganizationName: | UM SHORE MEDICAL CENTER AT EASTON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 219 S WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | EASTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216012913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108221000 | ||||||||
| FaxNumber: | 4108227834 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2006 | ||||||||
| LastUpdateDate: | 09/29/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| 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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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology | 261QR0206X | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology, Mammography | 273Y00000X | N | Hospital Units | Rehabilitation Unit | 291U00000X | N | Laboratories | Clinical Medical Laboratory | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 000305100 | 05 | MD | MEDICAID |