Basic Information
Provider Information
NPI: 1548264088
EntityType: 2
ReplacementNPI:  
OrganizationName: GOOD SHEPHERD HOSPICE
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 110 BI-COUNTY BLVD.
Address2: STE. 114
City: FARMINGDALE
State: NY
PostalCode: 11735
CountryCode: US
TelephoneNumber: 6314656300
FaxNumber: 6318287494
Practice Location
Address1: 110 BI-COUNTY BLVD.
Address2: STE. 114
City: FARMINGDALE
State: NY
PostalCode: 11735
CountryCode: US
TelephoneNumber: 6314656300
FaxNumber: 6318287494
Other Information
ProviderEnumerationDate: 06/13/2005
LastUpdateDate: 08/17/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: POLIT
AuthorizedOfficialFirstName: MARY ELLEN
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: EVP/CAO
AuthorizedOfficialTelephone: 6314656457
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
251G00000X251G00000XNYN AgenciesHospice Care, Community Based 
251G00000X5151501FNYY AgenciesHospice Care, Community Based 

ID Information
IDTypeStateIssuerDescription
0124358505NY MEDICAID


Home