Healthcare Provider Details

I. General information

NPI: 1093701708
Provider Name (Legal Business Name): SOUTH SHORE PLASTIC SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2005
Last Update Date: 03/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 CROWN COLONY DR SUITE 101
QUINCY MA
02169-0902
US

IV. Provider business mailing address

2300 CROWN COLONY DR SUITE 101
QUINCY MA
02169-0902
US

V. Phone/Fax

Practice location:
  • Phone: 617-786-7600
  • Fax: 617-786-7616
Mailing address:
  • Phone: 617-786-7600
  • Fax: 617-786-7616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number78298
License Number StateMA

VIII. Authorized Official

Name: FOUAD J SAMAHA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 617-786-7600