Provider Demographics
NPI:1124191820
Name:SOUTH SHORE ORTHOPAEDIC SPECIALISTS PC
Entity Type:Organization
Organization Name:SOUTH SHORE ORTHOPAEDIC SPECIALISTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:OWEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:MCCONVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:781-331-4450
Mailing Address - Street 1:797 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:SOUTH WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02190
Mailing Address - Country:US
Mailing Address - Phone:781-331-4450
Mailing Address - Fax:781-335-6047
Practice Address - Street 1:797 MAIN STREET
Practice Address - Street 2:
Practice Address - City:SOUTH WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190
Practice Address - Country:US
Practice Address - Phone:781-331-4450
Practice Address - Fax:781-335-6047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9785531Medicaid
MA9785531Medicaid