Provider Demographics
NPI:1407522212
Name:SHORESIDE INTERVENTIONAL PAIN LLC
Entity Type:Organization
Organization Name:SHORESIDE INTERVENTIONAL PAIN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:IRWIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-268-6090
Mailing Address - Street 1:PO BOX 15987
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4054
Mailing Address - Country:US
Mailing Address - Phone:972-792-5700
Mailing Address - Fax:214-506-1170
Practice Address - Street 1:2068 HAWTHORNE ST STE 101
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-2368
Practice Address - Country:US
Practice Address - Phone:972-792-5700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-20
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty