Provider Demographics
NPI:1891090403
Name:EASTERN SHORE INTERNAL MEDICINE, LLC
Entity Type:Organization
Organization Name:EASTERN SHORE INTERNAL MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:SNELLGROVE
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:251-990-1770
Mailing Address - Street 1:374 GREENO RD S
Mailing Address - Street 2:
Mailing Address - City:FAIRHOPE
Mailing Address - State:AL
Mailing Address - Zip Code:36532-1916
Mailing Address - Country:US
Mailing Address - Phone:251-990-1770
Mailing Address - Fax:251-990-1771
Practice Address - Street 1:374 GREENO RD S
Practice Address - Street 2:
Practice Address - City:FAIRHOPE
Practice Address - State:AL
Practice Address - Zip Code:36532-1916
Practice Address - Country:US
Practice Address - Phone:251-990-1770
Practice Address - Fax:251-990-1771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-13
Last Update Date:2011-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00016922207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000038007Medicaid
AL510-38007OtherBC/BS
AL25-10092OtherUNITED HEALTHCARE
AL000038007Medicare PIN
AL510-38007OtherBC/BS