Provider Demographics
NPI:1629070149
Name:SHORE MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:SHORE MEMORIAL HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:FACHE, MBA
Authorized Official - Phone:609-653-3545
Mailing Address - Street 1:1 E NEW YORK AVE
Mailing Address - Street 2:
Mailing Address - City:SOMERS POINT
Mailing Address - State:NJ
Mailing Address - Zip Code:08244-2340
Mailing Address - Country:US
Mailing Address - Phone:609-653-3545
Mailing Address - Fax:
Practice Address - Street 1:1 E NEW YORK AVE
Practice Address - Street 2:
Practice Address - City:SOMERS POINT
Practice Address - State:NJ
Practice Address - Zip Code:08244-2340
Practice Address - Country:US
Practice Address - Phone:609-653-3545
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-15
Last Update Date:2014-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ10103282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3674703Medicaid
NJ3674703Medicaid