Provider Demographics
NPI:1417094459
Name:SHORELINE FAMILY MEDICINE PC
Entity Type:Organization
Organization Name:SHORELINE FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:N
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:231-780-3300
Mailing Address - Street 1:5933 GRAND HAVEN RD
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49441-6011
Mailing Address - Country:US
Mailing Address - Phone:231-799-3300
Mailing Address - Fax:231-799-3322
Practice Address - Street 1:5933 GRAND HAVEN RD
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49441-6011
Practice Address - Country:US
Practice Address - Phone:231-799-3300
Practice Address - Fax:231-799-3322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013736207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5610080OtherBLUE CROSS
MI4309931Medicaid
MIG97079Medicare UPIN