Provider Demographics
NPI:1265670996
Name:EAST SHORE MEDICAL & PAIN MANAGEMENT PC
Entity type:Organization
Organization Name:EAST SHORE MEDICAL & PAIN MANAGEMENT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:S
Authorized Official - Last Name:BOLAND
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:717-652-5550
Mailing Address - Street 1:915 N MOUNTAIN RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17112-1793
Mailing Address - Country:US
Mailing Address - Phone:717-652-5550
Mailing Address - Fax:717-652-2488
Practice Address - Street 1:915 N MOUNTAIN RD
Practice Address - Street 2:SUITE C
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17112-1793
Practice Address - Country:US
Practice Address - Phone:717-652-5550
Practice Address - Fax:717-652-2488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-03
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC003322L2081N0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081N0008XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationNeuromuscular MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA6345680001Medicare NSC