Basic Information
| Provider Information | |||||||||
| NPI: | 1649305228 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHSIDE HOSPITAL DEPARTMENT OF CARDIOLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BAY SHORE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117068408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6319683000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 301 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BAY SHORE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117068408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6319683000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2007 | ||||||||
| LastUpdateDate: | 02/07/2008 | ||||||||
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| AuthorizedOfficialLastName: | MACK | ||||||||
| AuthorizedOfficialFirstName: | WINIFRED | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6319683000 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTHSIDE HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.