Provider Demographics
NPI:1336272665
Name:SOUTH SHORE SURGICENTER LLC
Entity type:Organization
Organization Name:SOUTH SHORE SURGICENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:POLSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-538-6600
Mailing Address - Street 1:2622 MARINA BAY DRIVE
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-6506
Mailing Address - Country:US
Mailing Address - Phone:281-538-6600
Mailing Address - Fax:281-535-2800
Practice Address - Street 1:2622 MARINA BAY DRIVE
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-6506
Practice Address - Country:US
Practice Address - Phone:281-538-6600
Practice Address - Fax:281-535-2800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX130038261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXOOO2CUOtherBLUE CROSS/BLUE SHIELD OF TEXAS PROVIDER ID
TX000843DMedicare PIN
TXOOO2CUOtherBLUE CROSS/BLUE SHIELD OF TEXAS PROVIDER ID