Basic Information
| Provider Information | |||||||||
| NPI: | 1437575396 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WINTHROP UNIVERSITY HOSPITAL ASSOCIATION | ||||||||
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| OtherOrganizationName: | WINTHROP UNIVERSITY CENTER FOR FAMILY DENTAL MEDICINE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 HICKSVILLE RD | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | BETHPAGE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117143471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165765810 | ||||||||
| FaxNumber: | 5765765801 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 OLD COUNTRY RD | ||||||||
| Address2: | SUITE 460 | ||||||||
| City: | MINEOLA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115014235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166632752 | ||||||||
| FaxNumber: | 5166639373 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2014 | ||||||||
| LastUpdateDate: | 03/14/2014 | ||||||||
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| AuthorizedOfficialLastName: | COLLINS | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5166632311 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
No ID Information.