=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174190326
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTH SHORE WOMENS CARE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2021
-----------------------------------------------------
Last Update Date | 06/07/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 750 MONTAUK HWY
-----------------------------------------------------
City | WEST ISLIP
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11795-4411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-523-0054
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21 COBBLERS LN
-----------------------------------------------------
City | DIX HILLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11746-5020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | LARISSA FOMITCHEVA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 347-523-0054
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------