Provider Demographics
NPI:1306042510
Name:SHORELINE INTERNAL MEDICINE, LLC
Entity Type:Organization
Organization Name:SHORELINE INTERNAL MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:SCHEIMANN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-453-4444
Mailing Address - Street 1:5 DURHAM RD
Mailing Address - Street 2:BLDG 3, C-1
Mailing Address - City:GUILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06437-2076
Mailing Address - Country:US
Mailing Address - Phone:203-453-4444
Mailing Address - Fax:203-458-9477
Practice Address - Street 1:5 DURHAM RD
Practice Address - Street 2:BLDG 3, C-1
Practice Address - City:GUILFORD
Practice Address - State:CT
Practice Address - Zip Code:06437-2076
Practice Address - Country:US
Practice Address - Phone:203-453-4444
Practice Address - Fax:203-458-9477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-25
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT033519207Q00000X
CT29519,31038,17718207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTF46994Medicare UPIN
E36204Medicare UPIN
CTD88758Medicare UPIN
CTF63348Medicare UPIN
C00839Medicare ID - Type UnspecifiedGROUP ID