Provider Demographics
NPI:1619674512
Name:SHORELINE ORTHOPAEDIC & SPORTS MEDICINE CLINIC P L C
Entity Type:Organization
Organization Name:SHORELINE ORTHOPAEDIC & SPORTS MEDICINE CLINIC P L C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHILDHOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:616-396-5855
Mailing Address - Street 1:340 KELLY ST
Mailing Address - Street 2:
Mailing Address - City:HUDSONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49426
Mailing Address - Country:US
Mailing Address - Phone:616-396-5855
Mailing Address - Fax:877-592-0688
Practice Address - Street 1:370 N 120TH AVE
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-2120
Practice Address - Country:US
Practice Address - Phone:616-396-5855
Practice Address - Fax:877-592-0688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-10
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty