Basic Information
| Provider Information | |||||||||
| NPI: | 1548343817 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HILLSIDE DIAGNOSTIC AND TREATMENT CENTER, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HILLSIDE SURGICARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18811 HILLSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | JAMAICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114231935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182646700 | ||||||||
| FaxNumber: | 7182646833 | ||||||||
| Practice Location | |||||||||
| Address1: | 18811 HILLSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | JAMAICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114231935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182646700 | ||||||||
| FaxNumber: | 7182646833 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 10/02/2008 | ||||||||
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| AuthorizedOfficialLastName: | WISSMANN | ||||||||
| AuthorizedOfficialFirstName: | DOUG | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | FINANCE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7182918200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 02100856 | 05 | NY | MEDICAID |