Provider Demographics
NPI:1548287360
Name:SOUTH SHORE INFECTIOUS DISEASES , PC
Entity type:Organization
Organization Name:SOUTH SHORE INFECTIOUS DISEASES , PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CAROLINA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLANDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-376-6075
Mailing Address - Street 1:40 EAST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706
Mailing Address - Country:US
Mailing Address - Phone:631-376-6075
Mailing Address - Fax:631-376-6091
Practice Address - Street 1:40 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8301
Practice Address - Country:US
Practice Address - Phone:631-376-6075
Practice Address - Fax:631-376-6091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY186715174400000X
207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWYXRV1Medicare PIN