Provider Demographics
NPI:1912111386
Name:SHORELINE EYE GROUP PC
Entity Type:Organization
Organization Name:SHORELINE EYE GROUP PC
Other - Org Name:SHORELINE EYE GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LIOR
Authorized Official - Middle Name:
Authorized Official - Last Name:HAIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-442-5663
Mailing Address - Street 1:741 BROAD STREET EXT
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-1347
Mailing Address - Country:US
Mailing Address - Phone:860-442-5663
Mailing Address - Fax:860-444-7778
Practice Address - Street 1:741 BROAD STREET EXT
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385
Practice Address - Country:US
Practice Address - Phone:860-442-5663
Practice Address - Fax:860-444-7778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTCC0552Medicare PIN
180000151Medicare PIN