1255653036 NPI number — SHORELINE NEUROLOGY, LLC

Table of content: (NPI 1255653036)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255653036 NPI number — SHORELINE NEUROLOGY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHORELINE NEUROLOGY, LLC
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:
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:
1255653036
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/22/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
180 WESTBROOK RD
Provider Second Line Business Mailing Address:
BUILDING 5
Provider Business Mailing Address City Name:
ESSEX
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06426-1517
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-767-1034
Provider Business Mailing Address Fax Number:
860-767-3434

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
180 WESTBROOK RD
Provider Second Line Business Practice Location Address:
BUILDING 5
Provider Business Practice Location Address City Name:
ESSEX
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06426-1517
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-767-1034
Provider Business Practice Location Address Fax Number:
860-767-3434
Provider Enumeration Date:
02/22/2010

Additional Information

Authorized Official

Authorized Official Last Name:
LIAN
Authorized Official First Name:
GANG
Authorized Official Middle Name:
Authorized Official Title or Position:
SOLE MEMBER
Authorized Official Telephone Number:
860-767-1034

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  041137 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 130000590 . This is a "MEDICARE PTAN" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 001411371 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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