Provider Demographics
NPI:1740591239
Name:SOUTH SHORE MEDICAL GROUP INC
Entity Type:Organization
Organization Name:SOUTH SHORE MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANDRIY
Authorized Official - Middle Name:
Authorized Official - Last Name:MATROFAYLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-885-0515
Mailing Address - Street 1:4515 SHORES DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70006-6808
Mailing Address - Country:US
Mailing Address - Phone:504-885-0515
Mailing Address - Fax:504-885-0517
Practice Address - Street 1:4515 SHORES DR
Practice Address - Street 2:SUITE 100
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006-6808
Practice Address - Country:US
Practice Address - Phone:504-885-0515
Practice Address - Fax:504-885-0517
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-29
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty