Provider Demographics
NPI:1669490462
Name:ATLANTIC SHORE PODIATRY,P.A.
Entity Type:Organization
Organization Name:ATLANTIC SHORE PODIATRY,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:GUTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:609-646-1991
Mailing Address - Street 1:2303 SHORE RD
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:08225-2148
Mailing Address - Country:US
Mailing Address - Phone:609-646-1991
Mailing Address - Fax:609-646-7329
Practice Address - Street 1:2303 SHORE RD
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:NJ
Practice Address - Zip Code:08225-2148
Practice Address - Country:US
Practice Address - Phone:609-646-1991
Practice Address - Fax:609-646-7329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00100700213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2826909Medicaid
NJT44758Medicare UPIN
NJ138645Medicare PIN