Basic Information
| Provider Information | |||||||||
| NPI: | 1275541104 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHSIDE HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | REHABILITATION UNIT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 972 BRUSH HOLLOW RD | ||||||||
| Address2: | 5TH FLOOR FINANCE ATTN: WILLIAM J. FUCHS | ||||||||
| City: | WESTBURY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115901740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5168766065 | ||||||||
| FaxNumber: | 5168765572 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BAY SHORE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117068408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5168766065 | ||||||||
| FaxNumber: | 5168765572 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 04/24/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CUSACK | ||||||||
| AuthorizedOfficialFirstName: | MICHELE | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT & CFO | ||||||||
| AuthorizedOfficialTelephone: | 5163216058 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | 5154000H | NY | Y | Hospital Units | Rehabilitation Unit |
No ID Information.