1750422705 NPI number — SOUTH SHORE PHYSICAL THERAPY P.C.

Table of content: (NPI 1750422705)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750422705 NPI number — SOUTH SHORE PHYSICAL THERAPY P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH SHORE PHYSICAL THERAPY P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750422705
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
220 MAIN ST
Provider Second Line Business Mailing Address:
SUITE 3
Provider Business Mailing Address City Name:
CENTER MORICHES
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11934-3504
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-878-4545
Provider Business Mailing Address Fax Number:
631-878-4573

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
220 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
CENTER MORICHES
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11934-3504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-878-4545
Provider Business Practice Location Address Fax Number:
631-878-4573
Provider Enumeration Date:
02/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HERRO
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
631-878-4545

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  5685-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1310650 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 51503 . This is a "AETNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 130065 . This is a "MPN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 3989276 . This is a "CIGNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 970755 . This is a "HIP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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