MEDICARE: SOUTH SHORE SPORTS & MUSCULAR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2251X0800X	Orthopedic Physical Therapist	5290	MA

General Provider Information

NPI Number	:	1104822576
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH SHORE SPORTS & MUSCULAR

Provider Business Mailing Address
First Line	:	90 LIBBEY INDUSTRIAL PKWY
Second Line	:	STE 103
City	:	EAST WEYMOUTH
State	:	MA
Zip	:	02189-3129
Country	:	US
Telephone Number	:	781-331-9600
Fax Number	:	781-335-1556

Provider Business Practice Location Address
First Line	:	90 LIBBEY INDUSTRIAL PKWY
Second Line	:	STE 103
City	:	EAST WEYMOUTH
State	:	MA
Zip	:	02189-3129
Country	:	US
Telephone Number	:	781-331-9600
Fax Number	:	781-335-1556

Authorized Official
Title or Position	:	GENERAL MANAGER
Name	:	MR. STEPHEN LALLY NEWCOMB
Credential	:
Telephone Number	:	781-331-9600

Provider Enumeration Date	:	06/22/2005
Last Update Date	:	12/19/2011

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