1992988703 NPI number — SOUTH SHORE DERMATOLOGY PHYSICIANS, P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992988703 NPI number — SOUTH SHORE DERMATOLOGY PHYSICIANS, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH SHORE DERMATOLOGY PHYSICIANS, 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:
6
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:
1992988703
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
31 ROCHE BROS WAY
Provider Second Line Business Mailing Address:
STE 200
Provider Business Mailing Address City Name:
NORTH EASTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02356
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-535-3376
Provider Business Mailing Address Fax Number:
508-535-3377

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
31 ROCHE BROS WAY
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
NORTH EASTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02356
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-535-3376
Provider Business Practice Location Address Fax Number:
508-535-3377
Provider Enumeration Date:
12/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
LYNN
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
508-535-3376

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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