Provider Demographics
NPI:1679927982
Name:LOWER SHORE IMMEDIATE CARE LLC
Entity Type:Organization
Organization Name:LOWER SHORE IMMEDIATE CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACTING AND CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:FROCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-789-6661
Mailing Address - Street 1:12302 SOMERSET AVE
Mailing Address - Street 2:SUITE A/B
Mailing Address - City:PRINCESS ANNE
Mailing Address - State:MD
Mailing Address - Zip Code:21853-3099
Mailing Address - Country:US
Mailing Address - Phone:410-651-0300
Mailing Address - Fax:302-947-4433
Practice Address - Street 1:12302 SOMERSET AVE
Practice Address - Street 2:SUITE A/B
Practice Address - City:PRINCESS ANNE
Practice Address - State:MD
Practice Address - Zip Code:21853-3099
Practice Address - Country:US
Practice Address - Phone:410-651-0300
Practice Address - Fax:302-947-4433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-22
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD533525Medicare PIN