Healthcare Provider Details

I. General information

NPI: 1255653036
Provider Name (Legal Business Name): SHORELINE NEUROLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2010
Last Update Date: 02/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 WESTBROOK RD BUILDING 5
ESSEX CT
06426-1517
US

IV. Provider business mailing address

180 WESTBROOK RD BUILDING 5
ESSEX CT
06426-1517
US

V. Phone/Fax

Practice location:
  • Phone: 860-767-1034
  • Fax: 860-767-3434
Mailing address:
  • Phone: 860-767-1034
  • Fax: 860-767-3434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number041137
License Number StateCT

VIII. Authorized Official

Name: DR. GANG LIAN
Title or Position: SOLE MEMBER
Credential: M.D., PH.D.
Phone: 860-767-1034