Provider Demographics
NPI:1629253513
Name:SHORE DERMATOLOGY LLC
Entity Type:Organization
Organization Name:SHORE DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:RISA
Authorized Official - Middle Name:JILL
Authorized Official - Last Name:GORIN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:732-462-5200
Mailing Address - Street 1:9 PROFESSIONAL CIRCLE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:COLTS NECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07722
Mailing Address - Country:US
Mailing Address - Phone:732-462-5200
Mailing Address - Fax:732-462-5212
Practice Address - Street 1:9 PROFESSIONAL CIRCLE
Practice Address - Street 2:SUITE 103
Practice Address - City:COLTS NECK
Practice Address - State:NJ
Practice Address - Zip Code:07722
Practice Address - Country:US
Practice Address - Phone:732-462-5200
Practice Address - Fax:732-462-5212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-09
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB07615100261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJI21465Medicare UPIN