Basic Information
Provider Information | |||||||||
NPI: | 1508845322 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HUNTINGTON HOSPITAL ASSOCIATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 270 PARK AVE | ||||||||
Address2: |   | ||||||||
City: | HUNTINGTON | ||||||||
State: | NY | ||||||||
PostalCode: | 117432787 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6313512200 | ||||||||
FaxNumber: | 6313512586 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/11/2006 | ||||||||
LastUpdateDate: | 10/06/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CUSACK | ||||||||
AuthorizedOfficialFirstName: | MICHELE | ||||||||
AuthorizedOfficialMiddleName: | LEE | ||||||||
AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT & CFO | ||||||||
AuthorizedOfficialTelephone: | 5163216058 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/06/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment | 273R00000X |   |   | N |   | Hospital Units | Psychiatric Unit |   | 282N00000X |   |   | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 00274355 | 05 | NY |   | MEDICAID | 00801 | 01 | NY | BLUE CROSS PSY | OTHER | 00101 | 01 | NY | BLUE CROSS | OTHER |