Basic Information
| Provider Information | |||||||||
| NPI: | 1619336260 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHWELL HEALTH | ||||||||
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| OtherOrganizationName: | NORTH SHORE LIJHS | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 SAINT ANDREWS LN | ||||||||
| Address2: | |||||||||
| City: | GLEN COVE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115422254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166747300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 101 SAINT ANDREWS LN | ||||||||
| Address2: | |||||||||
| City: | GLEN COVE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115422254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166747300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2016 | ||||||||
| LastUpdateDate: | 02/10/2016 | ||||||||
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| AuthorizedOfficialLastName: | SHERMAN | ||||||||
| AuthorizedOfficialFirstName: | BRADLEY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL STAFF DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5166747300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | F339965-1 | NY | Y | Hospital Units | Rehabilitation Unit |
No ID Information.