Basic Information
| Provider Information | |||||||||
| NPI: | 1003863820 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LONG ISLAND COLLEGE HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MEDICINE SPECIALTY GROUP AT LICH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 160 WATER ST | ||||||||
| Address2: | 20FL | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100384922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2122563682 | ||||||||
| FaxNumber: | 2122563538 | ||||||||
| Practice Location | |||||||||
| Address1: | 97 AMITY ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112016004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187802155 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 11/03/2009 | ||||||||
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| AuthorizedOfficialLastName: | PRIVMAN | ||||||||
| AuthorizedOfficialFirstName: | VLADIMIR | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGING EMPLOYEE | ||||||||
| AuthorizedOfficialTelephone: | 7187802155 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207RG0100X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 02420102 | 05 | NY | MEDICAID |