MEDICARE: SOUTH SHORE PLASTIC SURGERY

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1043212541	OTHER	MA	BLUE CROSS BLUE SHIELD
2	21222	OTHER	MA	HPHC

General Provider Information

NPI Number	:	1770719676
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH SHORE PLASTIC SURGERY

Provider Business Mailing Address
First Line	:	2300 CROWN COLONY DR
Second Line	:	SUITE 101
City	:	QUINCY
State	:	MA
Zip	:	02169-0902
Country	:	US
Telephone Number	:	617-786-7600
Fax Number	:	617-786-7616

Provider Business Practice Location Address
First Line	:	2300 CROWN COLONY DR
Second Line	:	SUITE 101
City	:	QUINCY
State	:	MA
Zip	:	02169-0902
Country	:	US
Telephone Number	:	617-786-7600
Fax Number	:	617-786-7616

Authorized Official
Title or Position	:	PRESIDENT
Name	:	FOUAD J SAMAHA
Credential	:	M.D.
Telephone Number	:	617-786-7600

Provider Enumeration Date	:	06/05/2009
Last Update Date	:	08/25/2009

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