Provider Demographics
NPI:1275782435
Name:SOUTH SHORE PHYSIATRY AND SPASTICITY MANAGEMENT
Entity type:Organization
Organization Name:SOUTH SHORE PHYSIATRY AND SPASTICITY MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KOELBEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-448-9303
Mailing Address - Street 1:132 ISLAND CREEK RD
Mailing Address - Street 2:
Mailing Address - City:DUXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02332-4323
Mailing Address - Country:US
Mailing Address - Phone:617-448-9303
Mailing Address - Fax:
Practice Address - Street 1:250 POND STREET
Practice Address - Street 2:
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-5351
Practice Address - Country:US
Practice Address - Phone:781-348-2202
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-12
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM19641OtherBLUE CROSS MA
MA110083193AMedicaid
MA110083193AMedicaid