=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902829286
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTH SHORE ANESTHESIA, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6314 BLACK HORSE PIKE
-----------------------------------------------------
City | EGG HARBOR TOWNSHIP
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08234-5543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-813-2190
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 237
-----------------------------------------------------
City | NORTHFIELD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08225-0237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER-PRESIDENT
-----------------------------------------------------
Name | MR. RAYMOND BERNARD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 609-813-2190
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------