Healthcare Provider Details

I. General information

NPI: 1841619954
Provider Name (Legal Business Name): SOUTH SHORE SURGICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2014
Last Update Date: 04/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10110 DONALD POWERS DRIVE SUITE 202
MUNSTER IN
46321-4057
US

IV. Provider business mailing address

10110 DONALD POWERS DRIVE SUITE 202
MUNSTER IN
46321-4057
US

V. Phone/Fax

Practice location:
  • Phone: 219-922-0222
  • Fax: 219-922-8899
Mailing address:
  • Phone: 219-922-0222
  • Fax: 219-922-8899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: ANN PELLAR
Title or Position: MANAGER
Credential:
Phone: 219-922-0222