1043208606 NPI number — SHORE HEALTH SERVICES CORPORATION

Table of content: (NPI 1043208606)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043208606 NPI number — SHORE HEALTH SERVICES CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHORE HEALTH SERVICES CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043208606
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
555 BAY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOMERS POINT
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08244-2533
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
609-927-9151
Provider Business Mailing Address Fax Number:
609-601-6472

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
555 BAY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOMERS POINT
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08244-2533
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-927-9151
Provider Business Practice Location Address Fax Number:
609-601-6472
Provider Enumeration Date:
10/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SLOAN
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
P
Authorized Official Title or Position:
CONTROLLER
Authorized Official Telephone Number:
609-927-9151

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  060109 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4462408 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 001260 . This is a "MEDICARE BLUE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0076902 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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