Provider Demographics
NPI:1568638732
Name:SHORELINE ALLERGY, P.C.
Entity Type:Organization
Organization Name:SHORELINE ALLERGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING/ACCTS MGR
Authorized Official - Prefix:MRS
Authorized Official - First Name:THERESE
Authorized Official - Middle Name:
Authorized Official - Last Name:PIPP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-799-8777
Mailing Address - Street 1:6215 HARVEY ST
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-9739
Mailing Address - Country:US
Mailing Address - Phone:231-799-8777
Mailing Address - Fax:231-798-7423
Practice Address - Street 1:6215 HARVEY ST
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-9739
Practice Address - Country:US
Practice Address - Phone:231-799-8777
Practice Address - Fax:231-798-7423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-07
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIFD055364207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0618234OtherBCBS PROVIDER
MI3478831Medicaid
MIFD055634OtherSTATE LICENSE
MI0M57350Medicare PIN