Provider Demographics
NPI:1134390966
Name:PLASTIC SURG ASSOC OF THE SOUTH SHORE
Entity type:Organization
Organization Name:PLASTIC SURG ASSOC OF THE SOUTH SHORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:A
Authorized Official - Last Name:FREDERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:781-749-9071
Mailing Address - Street 1:PO BOX 86
Mailing Address - Street 2:
Mailing Address - City:HINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02043-0086
Mailing Address - Country:US
Mailing Address - Phone:781-749-9071
Mailing Address - Fax:781-749-2133
Practice Address - Street 1:680 CENTRE ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-3308
Practice Address - Country:US
Practice Address - Phone:781-749-9071
Practice Address - Fax:781-749-2133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA29097208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA600169OtherTUFTS
MAM11183OtherBCBS MA
MAM11183OtherBCBS MA