Provider Demographics
NPI:1093701708
Name:SOUTH SHORE PLASTIC SURGERY
Entity Type:Organization
Organization Name:SOUTH SHORE PLASTIC SURGERY
Other - Org Name:BOSTON PLASTIC SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FOUAD
Authorized Official - Middle Name:J
Authorized Official - Last Name:SAMAHA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-786-7600
Mailing Address - Street 1:2300 CROWN COLONY DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-0902
Mailing Address - Country:US
Mailing Address - Phone:617-786-7600
Mailing Address - Fax:617-786-7616
Practice Address - Street 1:2300 CROWN COLONY DR
Practice Address - Street 2:SUITE 101
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-0902
Practice Address - Country:US
Practice Address - Phone:617-786-7600
Practice Address - Fax:617-786-7616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-27
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA78298208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0009857OtherNHP
MA21222OtherHPHC
MA9779787Medicaid
MAM20276Medicare ID - Type Unspecified