Provider Demographics
NPI:1710083043
Name:SHOELINE SURGICAL ASSOCIATES, INC.
Entity Type:Organization
Organization Name:SHOELINE SURGICAL ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:COPPE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-284-4114
Mailing Address - Street 1:70 KENYON AVE UNIT 325
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02879-4253
Mailing Address - Country:US
Mailing Address - Phone:401-284-4114
Mailing Address - Fax:401-789-1358
Practice Address - Street 1:70 KENYON AVE UNIT 325
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:RI
Practice Address - Zip Code:02879-4253
Practice Address - Country:US
Practice Address - Phone:401-284-4114
Practice Address - Fax:401-789-1358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRI6307174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty