Provider Demographics
NPI:1649575242
Name:SOUTHSHORE MEDICAL PRACTICE MANAGEMENT, INC
Entity Type:Organization
Organization Name:SOUTHSHORE MEDICAL PRACTICE MANAGEMENT, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:PACAUD
Authorized Official - Last Name:BREZAULT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-604-4020
Mailing Address - Street 1:56 W MAIN ST STE 203
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-8327
Mailing Address - Country:US
Mailing Address - Phone:631-604-4020
Mailing Address - Fax:
Practice Address - Street 1:56 W MAIN ST STE 203
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8327
Practice Address - Country:US
Practice Address - Phone:631-604-4020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-13
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY=========OtherEMPLOYER IDENTIFICATION NUMBER (EIN)