Basic Information
| Provider Information | |||||||||
| NPI: | 1821438656 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH SHORE LIJ INTERNAL MEDICINE AT NEW HYDE PARK PC | ||||||||
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| OtherOrganizationName: | NORTH SHORE - LIJ MEDICAL GROUP AT NASSAU QUEENS PULMONARY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 972 BRUSH HOLLOW RD | ||||||||
| Address2: | FINANCE 5TH FLOOR | ||||||||
| City: | WESTBURY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115901740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5168766065 | ||||||||
| FaxNumber: | 5168766600 | ||||||||
| Practice Location | |||||||||
| Address1: | 3003 NEW HYDE PARK RD | ||||||||
| Address2: | SUITE 303 | ||||||||
| City: | NEW HYDE PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110421206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5163260707 | ||||||||
| FaxNumber: | 5163261101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2013 | ||||||||
| LastUpdateDate: | 07/25/2022 | ||||||||
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| AuthorizedOfficialLastName: | CUSAK | ||||||||
| AuthorizedOfficialFirstName: | MICHELE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5164658162 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 07/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RP1001X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
No ID Information.