Provider Demographics
NPI:1528103900
Name:SOUTH SHORE EYE CARE, P.C.
Entity type:Organization
Organization Name:SOUTH SHORE EYE CARE, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:LISA
Authorized Official - Last Name:MCHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-298-5300
Mailing Address - Street 1:2110 DORCHESTER AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02124-5628
Mailing Address - Country:US
Mailing Address - Phone:617-298-5300
Mailing Address - Fax:617-296-3028
Practice Address - Street 1:2110 DORCHESTER AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02124-5628
Practice Address - Country:US
Practice Address - Phone:617-298-5300
Practice Address - Fax:617-296-3028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2010-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA077904207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9733655Medicaid
1308460001Medicare NSC
MA9733655Medicaid