Provider Demographics
NPI:1780686741
Name:SHORE RADIATION ONCOLOGY, LLC.
Entity Type:Organization
Organization Name:SHORE RADIATION ONCOLOGY, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARNIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-836-4130
Mailing Address - Street 1:425 JACK MARTIN BLVD
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08724-7732
Mailing Address - Country:US
Mailing Address - Phone:732-836-4130
Mailing Address - Fax:732-836-4036
Practice Address - Street 1:425 JACK MARTIN BLVD
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-7732
Practice Address - Country:US
Practice Address - Phone:732-836-4130
Practice Address - Fax:732-836-4036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA073488002085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ9083901Medicaid
NJ066580Medicare ID - Type UnspecifiedGROUP NJ MEDICARE #