Provider Demographics
NPI:1689795338
Name:SHORE MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:SHORE MEMORIAL HOSPITAL
Other - Org Name:SMH PROFESSIONAL SERVICES
Other - Org Type:Doing Business As
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:
Authorized Official - Phone:609-653-3545
Mailing Address - Street 1:1 EAST 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:609-653-3213
Mailing Address - Fax:609-653-3942
Practice Address - Street 1:1 EAST 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:609-653-3213
Practice Address - Fax:609-653-3942
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHORE MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-02
Last Update Date:2014-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA65533104100000X, 133N00000X, 207V00000X, 2080N0001X
NJ104100000X, 2080N0001X
NJ25MA04612900207RC0200X, 207RP1001X
NJMB052916207RH0003X
NJ25MA084897002085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Multi-Specialty
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8948909Medicaid
NJ8948909Medicaid
NJ171783Medicare UPIN