Provider Demographics
NPI:1396746483
Name:SOUTH SHORE MEDICAL CENTER
Entity type:Organization
Organization Name:SOUTH SHORE MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:JANOE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-334-2826
Mailing Address - Street 1:201 ENTERPRISE AVE
Mailing Address - Street 2:SUITE 900
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-3082
Mailing Address - Country:US
Mailing Address - Phone:281-334-2826
Mailing Address - Fax:281-334-1949
Practice Address - Street 1:201 ENTERPRISE AVE
Practice Address - Street 2:SUITE 900
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-3082
Practice Address - Country:US
Practice Address - Phone:281-334-2826
Practice Address - Fax:281-334-1949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty