Provider Demographics
NPI:1396767422
Name:SHORELINE GASTROENTEROLOGY PC
Entity type:Organization
Organization Name:SHORELINE GASTROENTEROLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GUY
Authorized Official - Middle Name:C
Authorized Official - Last Name:POWER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-737-2144
Mailing Address - Street 1:1150 E SHERMAN BLVD
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-1871
Mailing Address - Country:US
Mailing Address - Phone:231-737-2144
Mailing Address - Fax:231-737-0597
Practice Address - Street 1:1150 E SHERMAN BLVD
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1871
Practice Address - Country:US
Practice Address - Phone:231-737-2144
Practice Address - Fax:231-737-0597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301057496174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4555891Medicaid
MI4555891Medicaid