Basic Information
| Provider Information | |||||||||
| NPI: | 1093723488 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LONG ISLAND JEWISH MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | END STAGE RENAL DIALYSIS FACILITY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 972 BRUSH HOLLOW RD | ||||||||
| Address2: | 5TH FLOOOR FINANCE | ||||||||
| City: | WESTBURY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115901740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5168766000 | ||||||||
| FaxNumber: | 5168766600 | ||||||||
| Practice Location | |||||||||
| Address1: | 22022 HILLSIDE AVENUE | ||||||||
| Address2: | |||||||||
| City: | QUEENS VILLAGE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114272020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5168766000 | ||||||||
| FaxNumber: | 5168766600 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 11/28/2018 | ||||||||
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| AuthorizedOfficialLastName: | CUSACK | ||||||||
| AuthorizedOfficialFirstName: | MICHELE | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT & CFO | ||||||||
| AuthorizedOfficialTelephone: | 5163216058 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LONG ISLAND JEWISH MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | 7003004H | NY | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
No ID Information.