Provider Demographics
NPI:1275579765
Name:SHORELINE ORTHOPAEDIC & SPORTS MEDICINE CLINIC,PLC
Entity Type:Organization
Organization Name:SHORELINE ORTHOPAEDIC & SPORTS MEDICINE CLINIC,PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHILDHOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-396-5855
Mailing Address - Street 1:N . 370 120TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-2196
Mailing Address - Country:US
Mailing Address - Phone:616-396-5855
Mailing Address - Fax:616-396-5720
Practice Address - Street 1:370 120TH AVE
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-2196
Practice Address - Country:US
Practice Address - Phone:616-396-5855
Practice Address - Fax:616-396-5720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207X00000X, 332900000X
MI207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand SurgeryGroup - Multi-Specialty
No332900000XSuppliersNon-Pharmacy Dispensing SiteGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0888470001Medicare NSC
MI0G06055Medicare PIN