Provider Demographics
NPI:1700183373
Name:SOUTH SHORE NEUROLOGIC ASSOCIATES, PC
Entity Type:Organization
Organization Name:SOUTH SHORE NEUROLOGIC ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:DERITIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-758-4444
Mailing Address - Street 1:77 MEDFORD AVENUE
Mailing Address - Street 2:ROUTE 112
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772
Mailing Address - Country:US
Mailing Address - Phone:631-758-1910
Mailing Address - Fax:631-730-3467
Practice Address - Street 1:77 MEDFORD AVENUE
Practice Address - Street 2:ROUTE 112
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772
Practice Address - Country:US
Practice Address - Phone:631-758-1910
Practice Address - Fax:631-730-3467
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTH SHORE NEUROLOGIC ASSOCIATES PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-02-17
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1313140002332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY131314002Medicare Oscar/Certification