Provider Demographics
NPI:1790763159
Name:SOUTH SHORE SKIN CENTER, LLC
Entity Type:Organization
Organization Name:SOUTH SHORE SKIN CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:F
Authorized Official - Last Name:EISEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-747-0711
Mailing Address - Street 1:1 SCOBEE CIR
Mailing Address - Street 2:UNIT 3
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-4887
Mailing Address - Country:US
Mailing Address - Phone:508-747-0711
Mailing Address - Fax:508-746-9265
Practice Address - Street 1:1 SCOBEE CIR
Practice Address - Street 2:UNIT 3
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-4887
Practice Address - Country:US
Practice Address - Phone:508-747-0711
Practice Address - Fax:508-746-9265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-05
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA685603OtherTUFTS HEALTH PLAN
MAM17452OtherBLUE CROSS AND BLUE SHIEL
MAM20779Medicare PIN
MAM21440Medicare PIN