MEDICARE: SOUTH SHORE SC, LLC

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	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1508005976
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH SHORE SC, LLC

Provider Business Mailing Address
First Line	:	53 BRENTWOOD RD STE F
Second Line	:
City	:	BAY SHORE
State	:	NY
Zip	:	11706-6943
Country	:	US
Telephone Number	:	631-647-5550
Fax Number	:	631-647-5549

Provider Business Practice Location Address
First Line	:	53 BRENTWOOD RD
Second Line	:
City	:	BAY SHORE
State	:	NY
Zip	:	11706-6923
Country	:	US
Telephone Number	:	781-733-2235
Fax Number	:	973-506-1887

Authorized Official
Title or Position	:	FACILITY ADMINISTRATOR
Name	:	WENDY NIL MARTINEZ
Credential	:	RN
Telephone Number	:	631-647-5550

Provider Enumeration Date	:	02/09/2009
Last Update Date	:	11/16/2023

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