=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063692317
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHORE VASCULAR,PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2007
-----------------------------------------------------
Last Update Date | 11/16/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2435 HIGHWAY 34 184
-----------------------------------------------------
City | MANASQUAN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08736-1807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-292-9227
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2435 HIGHWAY 34 184
-----------------------------------------------------
City | MANASQUAN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08736-1807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. LOUIS GRELLA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 732-292-9227
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | MA61104
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------