Provider Demographics
NPI:1336281542
Name:SHORELINE FOOT & ANKLE ASSOCIATES P.C.
Entity Type:Organization
Organization Name:SHORELINE FOOT & ANKLE ASSOCIATES P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:DEYOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:231-733-1111
Mailing Address - Street 1:561 SEMINOLE RD
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-3719
Mailing Address - Country:US
Mailing Address - Phone:231-733-1111
Mailing Address - Fax:231-733-1144
Practice Address - Street 1:561 SEMINOLE RD
Practice Address - Street 2:
Practice Address - City:NORTON SHORES
Practice Address - State:MI
Practice Address - Zip Code:49444-3719
Practice Address - Country:US
Practice Address - Phone:231-733-1111
Practice Address - Fax:231-733-1144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3524970Medicaid
MI2759945Medicaid
MI4337945Medicaid
MI4337945Medicaid
MI2759945Medicaid
MI0F16415Medicare PIN
MIU18506Medicare UPIN