Healthcare Provider Details

I. General information

NPI: 1548771249
Provider Name (Legal Business Name): SHORE HEALTH SYSTEM, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2017
Last Update Date: 10/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 SHOREWAY DRIVE SUITE 130
QUEENSTOWN MD
21658
US

IV. Provider business mailing address

125 SHOREWAY DRIVE SUITE 130
QUEENSTOWN MD
21658
US

V. Phone/Fax

Practice location:
  • Phone: 410-827-3811
  • Fax: 410-827-3156
Mailing address:
  • Phone: 410-827-3811
  • Fax: 410-827-3156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QS1200X
TaxonomySleep Disorder Diagnostic Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KENNETH D KOZEL
Title or Position: PRESIDENT & CEO
Credential:
Phone: 410-822-1000