Provider Demographics
NPI:1154300259
Name:SOUTH SHORE NUCLEAR DIAGNOSTICS
Entity Type:Organization
Organization Name:SOUTH SHORE NUCLEAR DIAGNOSTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF BILLING
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:GRACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-993-1640
Mailing Address - Street 1:43 LEOPARD RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PAOLI
Mailing Address - State:PA
Mailing Address - Zip Code:19301-1552
Mailing Address - Country:US
Mailing Address - Phone:610-993-1640
Mailing Address - Fax:610-993-1651
Practice Address - Street 1:30 HEMPSTEAD AVE
Practice Address - Street 2:SUITE 246
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-4033
Practice Address - Country:US
Practice Address - Phone:516-764-5051
Practice Address - Fax:516-564-5113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY169782Medicare ID - Type Unspecified