Provider Demographics
NPI:1861696171
Name:SOUTH SHORE MEDICAL CARE, PC
Entity type:Organization
Organization Name:SOUTH SHORE MEDICAL CARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:ALBERT
Authorized Official - Last Name:LEWANDOSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:631-274-0777
Mailing Address - Street 1:16 VAN COTT RD
Mailing Address - Street 2:SUITE 2E
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-6519
Mailing Address - Country:US
Mailing Address - Phone:631-274-0777
Mailing Address - Fax:631-274-9499
Practice Address - Street 1:16 VAN COTT RD
Practice Address - Street 2:SUITE 2E
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729-6519
Practice Address - Country:US
Practice Address - Phone:631-274-0777
Practice Address - Fax:631-274-9499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY21762207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWEY021Medicare ID - Type Unspecified
NYH27968Medicare UPIN