Basic Information
| Provider Information | |||||||||
| NPI: | 1184666364 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LONG ISLAND CENTER FOR DIGESTIVE HEALTH LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 YORK RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | JAMISON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 189291098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155899024 | ||||||||
| FaxNumber: | 8337056301 | ||||||||
| Practice Location | |||||||||
| Address1: | 106 CHARLES LINDBERGH BLVD | ||||||||
| Address2: | |||||||||
| City: | UNIONDALE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115533632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5167941868 | ||||||||
| FaxNumber: | 5167941627 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 04/24/2020 | ||||||||
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| AuthorizedOfficialLastName: | HOHLFELD | ||||||||
| AuthorizedOfficialFirstName: | SHARON | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CO-TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 2155899024 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 04/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 33323 | 01 | NY | BCBS NON-PAR | OTHER | 20404489 | 05 | NY | MEDICAID | 33D1049916 | 01 | CLIA WAIVER | OTHER | 71395 | 01 | AAAHC | OTHER | BS9581364 | 01 | NY | DEA NUMBER | OTHER |