Provider Demographics
NPI:1164614137
Name:EASTERN SHORE CARE SERVICES, P.C.
Entity Type:Organization
Organization Name:EASTERN SHORE CARE SERVICES, P.C.
Other - Org Name:EASTERN SHORE AESTHETIC SERVICES PC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:RUCKER
Authorized Official - Last Name:STAGGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-929-7850
Mailing Address - Street 1:2935 THOUSAND OAKS
Mailing Address - Street 2:SUITE 294
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247-3312
Mailing Address - Country:US
Mailing Address - Phone:210-494-1100
Mailing Address - Fax:
Practice Address - Street 1:411 N SECTION ST
Practice Address - Street 2:
Practice Address - City:FAIRHOPE
Practice Address - State:AL
Practice Address - Zip Code:36532-2649
Practice Address - Country:US
Practice Address - Phone:251-591-3978
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-14
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALI486OtherMEDICARE GROUP
ALI486Medicare PIN