Provider Demographics
NPI:1275782435
Name:SOUTH SHORE PHYSIATRY AND SPASTICITY MANAGEMENT
Entity Type:Organization
Organization Name:SOUTH SHORE PHYSIATRY AND SPASTICITY MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KOELBEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:781-231-7026
Mailing Address - Street 1:P.O BOX 2190
Mailing Address - Street 2:
Mailing Address - City:W.PEABODY
Mailing Address - State:MA
Mailing Address - Zip Code:01960
Mailing Address - Country:US
Mailing Address - Phone:781-231-7026
Mailing Address - Fax:
Practice Address - Street 1:250 POND STREET
Practice Address - Street 2:
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-5351
Practice Address - Country:US
Practice Address - Phone:781-682-9700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-12
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA158723174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110083193AMedicaid
MAM19641OtherBLUE CROSS MA
MA110083193AMedicaid