Provider Demographics
NPI:1649494246
Name:SOUTH SHORE WOMEN'S HEALTH CARE PC
Entity type:Organization
Organization Name:SOUTH SHORE WOMEN'S HEALTH CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:RACHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:PROCTOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-428-2800
Mailing Address - Street 1:2690 S CLEVELAND AVENUE
Mailing Address - Street 2:
Mailing Address - City:ST. JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-3002
Mailing Address - Country:US
Mailing Address - Phone:269-428-2800
Mailing Address - Fax:269-428-7177
Practice Address - Street 1:2690 S CLEVELAND AVENUE
Practice Address - Street 2:
Practice Address - City:ST. JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-3002
Practice Address - Country:US
Practice Address - Phone:269-428-2800
Practice Address - Fax:269-428-7177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207V00000X
MIRP073123207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOA16065Medicare PIN