Provider Demographics
NPI:1538198767
Name:SHORELINE PODIATRY, PA
Entity type:Organization
Organization Name:SHORELINE PODIATRY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:B
Authorized Official - Last Name:KILLIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:361-334-1136
Mailing Address - Street 1:PO BOX 271416
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78427-1416
Mailing Address - Country:US
Mailing Address - Phone:361-334-1136
Mailing Address - Fax:361-334-1574
Practice Address - Street 1:613 ELIZABETH ST
Practice Address - Street 2:STE 513
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78404-2220
Practice Address - Country:US
Practice Address - Phone:361-881-8313
Practice Address - Fax:361-881-8323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1537332B00000X
213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDD0599OtherRAILROAD MEDICARE
TX0048MQOtherBCBS OF TX
TX174333801Medicaid
TX610351300OtherDEPARTMENT OF LABOR
TX174333802Medicaid
TX174333803Medicaid
TX5451980001OtherMEDICARE NSC
TX174333803Medicaid
TXU85546Medicare UPIN
TX174333802Medicaid