Basic Information
| Provider Information | |||||||||
| NPI: | 1457369381 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTH SHORE UNIVERSITY HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SOUTHSIDE HOSPITAL | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 972 BRUSH HOLLOW RD FL 5 | ||||||||
| Address2: | |||||||||
| 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: | 6319683001 | ||||||||
| FaxNumber: | 6319683315 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 04/15/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CUSACK | ||||||||
| AuthorizedOfficialFirstName: | MICHELE | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT & CFO | ||||||||
| AuthorizedOfficialTelephone: | 5163216058 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 5154000H | NY | Y | Hospitals | General Acute Care Hospital |
No ID Information.