Provider Demographics
NPI:1174190326
Name:SOUTH SHORE WOMENS CARE PLLC
Entity type:Organization
Organization Name:SOUTH SHORE WOMENS CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LARISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:FOMITCHEVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:347-523-0054
Mailing Address - Street 1:21 COBBLERS LN
Mailing Address - Street 2:
Mailing Address - City:DIX HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11746-5020
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:750 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-4411
Practice Address - Country:US
Practice Address - Phone:347-523-0054
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-07
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02834742Medicaid