MEDICARE: SOUTH COUNTY PHYSICIANS AND SURGEONS INC - OPTICAL SHOPE

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	332H00000X	Eyewear Supplier

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
2	0963	OTHER	RI	NEIGHBORHOOD HEALTH PLAN

General Provider Information

NPI Number	:	1649223744
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH COUNTY PHYSICIANS AND SURGEONS INC - OPTICAL SHOPE

Provider Business Mailing Address
First Line	:	65 BOSTON NECK ROAD
Second Line	:	SOUTH COUNTY EYE PHYSICIANS AND SURGEONS INC
City	:	NORTH KINGSTOWN
State	:	RI
Zip	:	02852-5704
Country	:	US
Telephone Number	:	401-295-0723
Fax Number	:	401-295-8870

Provider Business Practice Location Address
First Line	:	65 BOSTON NECK ROAD
Second Line	:	SOUTH COUNTY EYE PHYSICIANS AND SURGEONS INC
City	:	NORTH KINGSTOWN
State	:	RI
Zip	:	02852-5704
Country	:	US
Telephone Number	:	401-295-0723
Fax Number	:	401-295-8870

Authorized Official
Title or Position	:	PRESIDENT CEO
Name	:	DR. THOMAS J COGHLIN
Credential	:	MD
Telephone Number	:	401-294-4506

Provider Enumeration Date	:	05/18/2006
Last Update Date	:	08/22/2020

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