Basic Information
| Provider Information | |||||||||
| NPI: | 1841457967 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LICH FACULTY PRACTICE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LICH FACULTY PRACTICE PSYCHIATRIC ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 97 AMITY ST | ||||||||
| Address2: | 6TH FLOOR | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112016004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187804952 | ||||||||
| FaxNumber: | 7187801827 | ||||||||
| Practice Location | |||||||||
| Address1: | 97 AMITY ST | ||||||||
| Address2: | 6TH FLOOR | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112016004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187804952 | ||||||||
| FaxNumber: | 7187801827 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2008 | ||||||||
| LastUpdateDate: | 09/30/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BYRNE | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7187804997 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LONG ISLAND COLLEGE HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.