=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104210418
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHORE CARDIAC CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2015
-----------------------------------------------------
Last Update Date | 01/06/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 651 ROUTE 37 W
-----------------------------------------------------
City | TOMS RIVER
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08755-8060
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-286-6103
-----------------------------------------------------
Fax | 732-518-5252
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 651 ROUTE 37 W
-----------------------------------------------------
City | TOMS RIVER
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08755-8060
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-286-6103
-----------------------------------------------------
Fax | 732-518-5252
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. BHAVNA MOHANDAS
-----------------------------------------------------
Credential | MD, FACC
-----------------------------------------------------
Telephone | 732-330-2566
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | 25MA09530100
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------