Provider Demographics
NPI:1679656813
Name:SHORE SURGICAL PROFESSIONAL ASSOCIATES
Entity Type:Organization
Organization Name:SHORE SURGICAL PROFESSIONAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL TRAUMA SURGERYOCCUPATIONAL
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:C
Authorized Official - Last Name:GODFREY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-646-1739
Mailing Address - Street 1:705 WHITE HORSE PIKE
Mailing Address - Street 2:
Mailing Address - City:ABSECON
Mailing Address - State:NJ
Mailing Address - Zip Code:08201-1468
Mailing Address - Country:US
Mailing Address - Phone:609-646-1739
Mailing Address - Fax:609-646-7247
Practice Address - Street 1:705 WHITE HORSE PIKE
Practice Address - Street 2:
Practice Address - City:ABSECON
Practice Address - State:NJ
Practice Address - Zip Code:08201-1468
Practice Address - Country:US
Practice Address - Phone:609-646-1739
Practice Address - Fax:609-646-7247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2009-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA14407174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3099202Medicaid
NJ3099202Medicaid
NJD19919Medicare UPIN