Organization
SOUTH SHORE WOMENS CARE PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
LARISSA FOMITCHEVA MD (PRESIDENT)
(347) 523-0054
Entity
Organization
Contact information
Practice address
750 MONTAUK HWY, WEST ISLIP, NY 11795-4411
(347) 523-0054
Mailing address
21 COBBLERS LN, DIX HILLS, NY 11746-5020
Taxonomy
Speciality
Code
Description
License number
State
207V00000X
Obstetrics & Gynecology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
02834742
—
NY
Enumeration date
06/07/2021
Last updated
06/07/2021
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