Provider Demographics
NPI:1518371996
Name:SHORESIDE MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:SHORESIDE MEDICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:TRACI
Authorized Official - Middle Name:LW
Authorized Official - Last Name:POSTELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-316-4111
Mailing Address - Street 1:449 ROCKEFELLER DR
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA
Mailing Address - State:FL
Mailing Address - Zip Code:32168-8937
Mailing Address - Country:US
Mailing Address - Phone:386-957-3800
Mailing Address - Fax:386-426-5939
Practice Address - Street 1:419 EAST THIRD AVE
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32169
Practice Address - Country:US
Practice Address - Phone:386-957-3800
Practice Address - Fax:386-426-5939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-13
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8699208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty