Provider Demographics
NPI:1497232722
Name:SOUTH SHORE FAMILY MEDICAL CLINIC
Entity Type:Organization
Organization Name:SOUTH SHORE FAMILY MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE PRACTITIONER
Authorized Official - Phone:606-498-4232
Mailing Address - Street 1:37 CHRISTOPHER DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH SHORE
Mailing Address - State:KY
Mailing Address - Zip Code:41175-9447
Mailing Address - Country:US
Mailing Address - Phone:594-210-4458
Mailing Address - Fax:
Practice Address - Street 1:74 BIGGS LN
Practice Address - Street 2:
Practice Address - City:SOUTH SHORE
Practice Address - State:KY
Practice Address - Zip Code:41175-7846
Practice Address - Country:US
Practice Address - Phone:606-498-4232
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-19
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3006463363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty