Provider Demographics
NPI:1083657464
Name:SOUTH SHORE DIALYSIS INC. - BELLMORE
Entity type:Organization
Organization Name:SOUTH SHORE DIALYSIS INC. - BELLMORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CORENE
Authorized Official - Middle Name:
Authorized Official - Last Name:KORBA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-644-9276
Mailing Address - Street 1:250 PETTIT AVE
Mailing Address - Street 2:
Mailing Address - City:BELLMORE
Mailing Address - State:NY
Mailing Address - Zip Code:11710-3657
Mailing Address - Country:US
Mailing Address - Phone:516-679-3090
Mailing Address - Fax:
Practice Address - Street 1:250 PETTIT AVE
Practice Address - Street 2:
Practice Address - City:BELLMORE
Practice Address - State:NY
Practice Address - Zip Code:11710-3657
Practice Address - Country:US
Practice Address - Phone:516-679-3090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2906202R261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00803892Medicaid
NY009261OtherEMPIRE BLUE CROISS
NY009261OtherEMPIRE BLUE CROISS