Provider Demographics
NPI:1245213875
Name:SOUTH SHORE PEDIATRICS PC
Entity Type:Organization
Organization Name:SOUTH SHORE PEDIATRICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:RAIFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-945-2600
Mailing Address - Street 1:PO BOX 940073
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11694-0073
Mailing Address - Country:US
Mailing Address - Phone:718-945-2600
Mailing Address - Fax:718-945-3987
Practice Address - Street 1:431 BEACH 129TH ST
Practice Address - Street 2:
Practice Address - City:BELLE HARBOR
Practice Address - State:NY
Practice Address - Zip Code:11694-1516
Practice Address - Country:US
Practice Address - Phone:718-945-2600
Practice Address - Fax:718-945-3987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6012692208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01427081Medicaid