Provider Demographics
NPI:1497750798
Name:SHORELINE MEDICAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:SHORELINE MEDICAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:P
Authorized Official - Last Name:SWENSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-245-4933
Mailing Address - Street 1:1353 BOSTON POST RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:CT
Mailing Address - Zip Code:06443-3445
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1353 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:CT
Practice Address - Zip Code:06443-3445
Practice Address - Country:US
Practice Address - Phone:203-245-4933
Practice Address - Fax:203-245-4399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-15
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
CT006159363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001222280Medicaid
CT001378422Medicaid
CT001421916Medicaid
CTS55843Medicare UPIN
CT001421916Medicaid
CT080001679Medicare ID - Type UnspecifiedHELEN EDE MEDICARE #
CTI07599Medicare UPIN
CT970000409Medicare ID - Type UnspecifiedJOSEPH SLATER MEDICARE #
CT080001338Medicare ID - Type UnspecifiedJENNIFER SWENSON MEDICARE
CTC07079Medicare UPIN
CTG73163Medicare UPIN
CT970000578Medicare ID - Type UnspecifiedAIMEE CRISCUOLO MEDICARE
CT001378422Medicaid