Basic Information
| Provider Information | |||||||||
| NPI: | 1073578779 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH SHORE NEPHROLOGY, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 47 OBERY STREET | ||||||||
| Address2: | STE 1A | ||||||||
| City: | PLYMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023602229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087474883 | ||||||||
| FaxNumber: | 5087476661 | ||||||||
| Practice Location | |||||||||
| Address1: | 47 OBERY STREET | ||||||||
| Address2: | STE 1A | ||||||||
| City: | PLYMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023602229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087474883 | ||||||||
| FaxNumber: | 5087476661 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | LAZOWSKI | ||||||||
| AuthorizedOfficialFirstName: | PIOTR | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 5087474883 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DOCTOR | ||||||||
| NPICertificationDate: | 04/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | MA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 412162 | 01 | MA | TUFTS HEALTH PLAN PAYEE N | OTHER | 9749331 | 05 | MA | MEDICAID | M18774 | 01 | MA | BLUE SHIELD GROUP NUMBER | OTHER |