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
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | 251G00000X | NY | N |   | Agencies | Hospice Care, Community Based |   | 251G00000X | 5151501F | NY | Y |   | Agencies | Hospice Care, Community Based |   |
ID Information
ID | Type | State | Issuer | Description | 01243585 | 05 | NY |   | MEDICAID |