Basic Information
Provider Information | |||||||||
NPI: | 1568459204 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | THE LONG ISLAND HOME | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SOUTH OAKS HOSPITAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 400 SUNRISE HWY | ||||||||
Address2: |   | ||||||||
City: | AMITYVILLE | ||||||||
State: | NY | ||||||||
PostalCode: | 117012508 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6312644000 | ||||||||
FaxNumber: | 6313960025 | ||||||||
Practice Location | |||||||||
Address1: | 400 SUNRISE HWY | ||||||||
Address2: |   | ||||||||
City: | AMITYVILLE | ||||||||
State: | NY | ||||||||
PostalCode: | 117012508 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6312644000 | ||||||||
FaxNumber: | 6313960025 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/27/2005 | ||||||||
LastUpdateDate: | 06/27/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CUSACK | ||||||||
AuthorizedOfficialFirstName: | MICHELE | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT & CFO | ||||||||
AuthorizedOfficialTelephone: | 5163216058 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/27/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283Q00000X |   |   | Y |   | Hospitals | Psychiatric Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 00274391 | 05 | NY |   | MEDICAID |