MEDICARE: SOUTH SHORE PEDIATRICS PC

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	208000000X	Pediatrics Physician	6012692	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1245213875
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH SHORE PEDIATRICS PC

Provider Business Mailing Address
First Line	:	PO BOX 940073
Second Line	:
City	:	ROCKAWAY PARK
State	:	NY
Zip	:	11694-0073
Country	:	US
Telephone Number	:	718-945-2600
Fax Number	:	718-945-3987

Provider Business Practice Location Address
First Line	:	431 BEACH 129TH ST
Second Line	:
City	:	BELLE HARBOR
State	:	NY
Zip	:	11694-1516
Country	:	US
Telephone Number	:	718-945-2600
Fax Number	:	718-945-3987

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MARK A RAIFMAN
Credential	:	MD
Telephone Number	:	718-945-2600

Provider Enumeration Date	:	11/29/2005
Last Update Date	:	08/22/2020

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