Provider Demographics
NPI:1255653036
Name:SHORELINE NEUROLOGY, LLC
Entity Type:Organization
Organization Name:SHORELINE NEUROLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:GANG
Authorized Official - Middle Name:
Authorized Official - Last Name:LIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:860-767-1034
Mailing Address - Street 1:180 WESTBROOK RD
Mailing Address - Street 2:BUILDING 5
Mailing Address - City:ESSEX
Mailing Address - State:CT
Mailing Address - Zip Code:06426-1517
Mailing Address - Country:US
Mailing Address - Phone:860-767-1034
Mailing Address - Fax:860-767-3434
Practice Address - Street 1:180 WESTBROOK RD
Practice Address - Street 2:BUILDING 5
Practice Address - City:ESSEX
Practice Address - State:CT
Practice Address - Zip Code:06426-1517
Practice Address - Country:US
Practice Address - Phone:860-767-1034
Practice Address - Fax:860-767-3434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-22
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0411372084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT130000590OtherMEDICARE PTAN
CT001411371Medicaid
CT130000590OtherMEDICARE PTAN