Provider Demographics
NPI:1710387386
Name:ASSOCIATES OF SOUTH SHORE DERMATOLOGY LLC
Entity Type:Organization
Organization Name:ASSOCIATES OF SOUTH SHORE DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:G
Authorized Official - Last Name:WERTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-773-7431
Mailing Address - Street 1:300 CONGRESS ST
Mailing Address - Street 2:STE 408
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169
Mailing Address - Country:US
Mailing Address - Phone:617-773-7431
Mailing Address - Fax:617-773-9592
Practice Address - Street 1:300 CONGRESS ST
Practice Address - Street 2:STE 408
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-0907
Practice Address - Country:US
Practice Address - Phone:617-773-7431
Practice Address - Fax:617-773-9592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-02
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA73556207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty