Healthcare Provider Details

I. General information

NPI: 1740216035
Provider Name (Legal Business Name): SHORELINE PODIATRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 SALT POND RD UNIT E-1
WAKEFIELD RI
02879-4314
US

IV. Provider business mailing address

24 SALT POND RD UNIT E-1
WAKEFIELD RI
02879-4314
US

V. Phone/Fax

Practice location:
  • Phone: 401-783-2424
  • Fax: 401-789-2095
Mailing address:
  • Phone: 401-783-2424
  • Fax: 401-789-2095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: JAMES I MCCORMICK
Title or Position: PRESIDENT
Credential: DPM
Phone: 401-783-2424