Basic Information
| Provider Information | |||||||||
| NPI: | 1316041924 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARY IMMACULATE HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15211 89TH AVE | ||||||||
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| City: | JAMAICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114323730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187437090 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11449 SUTPHIN BLVD | ||||||||
| Address2: | |||||||||
| City: | JAMAICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114341022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185586622 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2006 | ||||||||
| LastUpdateDate: | 12/21/2007 | ||||||||
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| AuthorizedOfficialLastName: | ADELMAN | ||||||||
| AuthorizedOfficialFirstName: | MARINA | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING DEPARTMENT | ||||||||
| AuthorizedOfficialTelephone: | 7187437090 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | 026852 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
No ID Information.