Basic Information
Provider Information
NPI: 1700480050
EntityType: 2
ReplacementNPI:  
OrganizationName: STATEN ISLAND UNIVERSITY HOSPITAL
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: OPIOID TREATMENT PROGRAM
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 392 SEGUINE AVE
Address2:  
City: STATEN ISLAND
State: NY
PostalCode: 103093906
CountryCode: US
TelephoneNumber: 7182263815
FaxNumber: 7182268144
Practice Location
Address1: 392 SEGUINE AVE
Address2:  
City: STATEN ISLAND
State: NY
PostalCode: 103093906
CountryCode: US
TelephoneNumber: 7182263815
FaxNumber: 7182268144
Other Information
ProviderEnumerationDate: 11/27/2020
LastUpdateDate: 02/05/2021
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: CUSACK
AuthorizedOfficialFirstName: MICHELE
AuthorizedOfficialMiddleName: L
AuthorizedOfficialTitleorPosition: SENIOR VICE PRESIDENT & CFO
AuthorizedOfficialTelephone: 5163216058
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MRS.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 02/05/2021

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QM2800X  Y Ambulatory Health Care FacilitiesClinic/CenterMethadone Clinic

No ID Information.


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