Basic Information
Provider Information | |||||||||
NPI: | 1174627616 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LUTHERAN MEDICAL CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1338 E 69TH ST | ||||||||
Address2: |   | ||||||||
City: | BROOKLYN | ||||||||
State: | NY | ||||||||
PostalCode: | 112345703 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7182511231 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3414 CHURCH AVE | ||||||||
Address2: |   | ||||||||
City: | BROOKLYN | ||||||||
State: | NY | ||||||||
PostalCode: | 112032714 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7189409425 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/12/2006 | ||||||||
LastUpdateDate: | 06/16/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HILAIRE | ||||||||
AuthorizedOfficialFirstName: | MARC | ||||||||
AuthorizedOfficialMiddleName: | RICHARD | ||||||||
AuthorizedOfficialTitleorPosition: | INTERNIST | ||||||||
AuthorizedOfficialTelephone: | 7189409425 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 224855 | NY | Y |   | Ambulatory Health Care Facilities | Clinic/Center |   |
No ID Information.