Basic Information
| Provider Information | |||||||||
| NPI: | 1205844768 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LONG ISLAND COLLEGE HOSPITAL | ||||||||
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| OtherOrganizationName: | LICH PLASTIC AND RECONSTRUCTION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 160 WATER STREET | ||||||||
| Address2: | 20FL | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2122563682 | ||||||||
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| Practice Location | |||||||||
| Address1: | 185 MONTAGUE STREET | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2122563682 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 11/05/2009 | ||||||||
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| AuthorizedOfficialLastName: | HACKETT | ||||||||
| AuthorizedOfficialFirstName: | DEBORAH | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGING EMPLOYEE | ||||||||
| AuthorizedOfficialTelephone: | 2122563421 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | VP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207YX0905X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngology/Facial Plastic Surgery |
No ID Information.