Provider Demographics
NPI:1548452659
Name:SHORELINE REHAB PLC
Entity type:Organization
Organization Name:SHORELINE REHAB PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:ILPT
Authorized Official - Phone:231-893-6655
Mailing Address - Street 1:9219 WATER ST
Mailing Address - Street 2:
Mailing Address - City:MONTAGUE
Mailing Address - State:MI
Mailing Address - Zip Code:49437-9206
Mailing Address - Country:US
Mailing Address - Phone:231-893-6655
Mailing Address - Fax:231-893-4902
Practice Address - Street 1:9219 WATER ST
Practice Address - Street 2:
Practice Address - City:MONTAGUE
Practice Address - State:MI
Practice Address - Zip Code:49437-9206
Practice Address - Country:US
Practice Address - Phone:231-893-6655
Practice Address - Fax:231-893-4902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-13
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501008363174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650F157060MOtherBLUE CROSS BLUE SHIELD
MI650F157050OtherBLUE CROSS BLUE SHIELD
MI1908559Medicaid
MIDE3646OtherRAILROAD MEDICARE GROUP
MI0P28020002Medicare PIN
MI0P28020002MMedicare PIN
MI650F157050OtherBLUE CROSS BLUE SHIELD
MI0P28020001Medicare PIN