Provider Demographics
NPI:1801896998
Name:SOUTH SHORE RADIATION ONCOLOGY ASSOCIATES P C
Entity type:Organization
Organization Name:SOUTH SHORE RADIATION ONCOLOGY ASSOCIATES P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:MULLEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-632-3380
Mailing Address - Street 1:PO BOX 10266
Mailing Address - Street 2:
Mailing Address - City:UNIONDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11555-0266
Mailing Address - Country:US
Mailing Address - Phone:516-632-3303
Mailing Address - Fax:516-632-3325
Practice Address - Street 1:1 HEALTHY WAY
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:NY
Practice Address - Zip Code:11572-1551
Practice Address - Country:US
Practice Address - Phone:516-632-3303
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02544287Medicaid
NYW35811Medicare ID - Type Unspecified