Provider Demographics
NPI:1093719809
Name:SHORE GASTROENTEROLOGY ASSOCIATES PC
Entity Type:Organization
Organization Name:SHORE GASTROENTEROLOGY ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF COMPANY
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDERIC
Authorized Official - Middle Name:R
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-517-0060
Mailing Address - Street 1:1907 HIGHWAY 35
Mailing Address - Street 2:STE 1
Mailing Address - City:OAKHURST
Mailing Address - State:NJ
Mailing Address - Zip Code:07755-2760
Mailing Address - Country:US
Mailing Address - Phone:732-517-0060
Mailing Address - Fax:732-517-8589
Practice Address - Street 1:1907 HIGHWAY 35
Practice Address - Street 2:STE 1
Practice Address - City:OAKHURST
Practice Address - State:NJ
Practice Address - Zip Code:07755-2760
Practice Address - Country:US
Practice Address - Phone:732-517-0060
Practice Address - Fax:723-517-8589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-09
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA047267000174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3385809Medicaid
NJ700139Medicare PIN