Basic Information
| Provider Information | |||||||||
| NPI: | 1407522212 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHORESIDE INTERVENTIONAL PAIN LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 15987 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049154054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727925700 | ||||||||
| FaxNumber: | 2145061170 | ||||||||
| Practice Location | |||||||||
| Address1: | 2068 HAWTHORNE ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | SARASOTA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342392368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727925700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2021 | ||||||||
| LastUpdateDate: | 08/20/2021 | ||||||||
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| AuthorizedOfficialLastName: | IRWIN | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4792686090 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 08/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 208VP0014X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
No ID Information.