Healthcare Provider Details

I. General information

NPI: 1407445620
Provider Name (Legal Business Name): SHORELINE ANESTHESIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2021
Last Update Date: 01/12/2021
Certification Date: 01/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 N UNION ST UNIT 533
KOKOMO IN
46901-5045
US

IV. Provider business mailing address

101 N UNION ST UNIT 533
KOKOMO IN
46901-5045
US

V. Phone/Fax

Practice location:
  • Phone: 718-644-0622
  • Fax:
Mailing address:
  • Phone: 718-644-0622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number
License Number State

VIII. Authorized Official

Name: DR. THOMAS JOHN SCHAFFER
Title or Position: PRESIDENT
Credential: DDS
Phone: 718-644-0622