Basic Information
| Provider Information | |||||||||
| NPI: | 1861425597 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHORELINE ORTHOPEDICS & SPORTS MEDICINE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12 BOKUM RD | ||||||||
| Address2: | |||||||||
| City: | ESSEX | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064261500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8607679053 | ||||||||
| FaxNumber: | 8607671146 | ||||||||
| Practice Location | |||||||||
| Address1: | 12 BOKUM RD | ||||||||
| Address2: | |||||||||
| City: | ESSEX | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064261500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8607679053 | ||||||||
| FaxNumber: | 8607671146 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 12/08/2011 | ||||||||
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| AuthorizedOfficialLastName: | WHITE | ||||||||
| AuthorizedOfficialFirstName: | MARTIN | ||||||||
| AuthorizedOfficialMiddleName: | JEFFREY | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 8607679053 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 027273 | CT | N | Suppliers | Durable Medical Equipment & Medical Supplies | 207X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 004246824 | 05 | CT | MEDICAID |