Provider Demographics
NPI:1700054954
Name:SOUTH SHORE MEDICAL CARE &DIAGNOSTIC, PC
Entity Type:Organization
Organization Name:SOUTH SHORE MEDICAL CARE &DIAGNOSTIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:S
Authorized Official - Last Name:COLADNER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:631-737-5143
Mailing Address - Street 1:4250 VETERANS MEMORIAL HWY
Mailing Address - Street 2:SUITE 1020
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-4000
Mailing Address - Country:US
Mailing Address - Phone:631-737-5143
Mailing Address - Fax:631-737-5224
Practice Address - Street 1:4250 VETERANS MEMORIAL HWY
Practice Address - Street 2:SUITE 1020
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-4000
Practice Address - Country:US
Practice Address - Phone:631-737-5143
Practice Address - Fax:631-737-5224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-11
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYC09215111N00000X
NY1867861208100000X
NY2192491208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F82680Medicare UPIN
U74591Medicare UPIN
H26521Medicare UPIN