Provider Demographics
NPI:1003879842
Name:SHOREVIEW MEDICAL ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:SHOREVIEW MEDICAL ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MISTY
Authorized Official - Middle Name:LAINE
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:CPT, CPC
Authorized Official - Phone:910-458-8867
Mailing Address - Street 1:PO BOX 317
Mailing Address - Street 2:
Mailing Address - City:CAROLINA BEACH
Mailing Address - State:NC
Mailing Address - Zip Code:28428-0317
Mailing Address - Country:US
Mailing Address - Phone:910-458-8867
Mailing Address - Fax:910-458-8764
Practice Address - Street 1:1328 N LAKE PARK BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:CAROLINA BEACH
Practice Address - State:NC
Practice Address - Zip Code:28428-3945
Practice Address - Country:US
Practice Address - Phone:910-458-8867
Practice Address - Fax:910-458-8764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC016AFOtherBLUE CROSS AND BLUE SHIEL
NC89016AFMedicaid
NCF91663Medicare UPIN
NC016AFOtherBLUE CROSS AND BLUE SHIEL