Provider Demographics
NPI:1609874643
Name:SHORELINE PEDIATRICS PLC
Entity Type:Organization
Organization Name:SHORELINE PEDIATRICS PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LEANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOLENDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-773-7837
Mailing Address - Street 1:2680 VULCAN ST
Mailing Address - Street 2:
Mailing Address - City:NORTON SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:49444-2344
Mailing Address - Country:US
Mailing Address - Phone:231-773-7837
Mailing Address - Fax:231-773-7943
Practice Address - Street 1:684 HARVEY ST
Practice Address - Street 2:SUITE 201
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-4274
Practice Address - Country:US
Practice Address - Phone:231-773-7837
Practice Address - Fax:231-773-7943
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-13
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI500F113130OtherBCBS MICHIGAN