Healthcare Provider Details

I. General information

NPI: 1093745333
Provider Name (Legal Business Name): SOUTH SHORE PHYSICIANS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 11/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3589 HYLAN BLVD
STATEN ISLAND NY
10308-3513
US

IV. Provider business mailing address

3589 HYLAN BLVD
STATEN ISLAND NY
10308-3513
US

V. Phone/Fax

Practice location:
  • Phone: 718-966-3700
  • Fax:
Mailing address:
  • Phone: 718-966-3700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number162022
License Number StateNY

VIII. Authorized Official

Name: DR. PAUL C GAZZARA
Title or Position: ADMINISTRATOR
Credential: M.D.
Phone: 718-966-3700