Provider Demographics
NPI:1861122871
Name:SOUTH SHORE OMS PC
Entity type:Organization
Organization Name:SOUTH SHORE OMS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:DOHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-479-2990
Mailing Address - Street 1:19249 ALLEN RD
Mailing Address - Street 2:
Mailing Address - City:BROWNSTOWN TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48183-1189
Mailing Address - Country:US
Mailing Address - Phone:734-479-2990
Mailing Address - Fax:
Practice Address - Street 1:19249 ALLEN RD
Practice Address - Street 2:
Practice Address - City:BROWNSTOWN TWP
Practice Address - State:MI
Practice Address - Zip Code:48183-1189
Practice Address - Country:US
Practice Address - Phone:734-479-2990
Practice Address - Fax:734-479-2991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-13
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery