Provider Demographics
NPI:1538126941
Name:SHORELINE PEDIATRICS & ADOLESCENT MEDICINE, P.C.
Entity Type:Organization
Organization Name:SHORELINE PEDIATRICS & ADOLESCENT MEDICINE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:H
Authorized Official - Last Name:GLEICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-421-3600
Mailing Address - Street 1:1110 DURHAM RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:CT
Mailing Address - Zip Code:06443-1858
Mailing Address - Country:US
Mailing Address - Phone:203-421-3600
Mailing Address - Fax:203-421-3627
Practice Address - Street 1:1110 DURHAM RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:CT
Practice Address - Zip Code:06443-1858
Practice Address - Country:US
Practice Address - Phone:203-421-3600
Practice Address - Fax:203-421-3627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty