Basic Information
| Provider Information | |||||||||
| NPI: | 1891861787 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LONG ISLAND JEWISH MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | LIJ TRANSITIONS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 972 BRUSH HOLLOW ROAD | ||||||||
| Address2: | 5TH FLOOR FINANCE | ||||||||
| City: | WESTBURY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5168766000 | ||||||||
| FaxNumber: | 5168766600 | ||||||||
| Practice Location | |||||||||
| Address1: | 27005 76TH AVE | ||||||||
| Address2: | |||||||||
| City: | NEW HYDE PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110401433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5168766000 | ||||||||
| FaxNumber: | 5168766600 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2006 | ||||||||
| LastUpdateDate: | 11/28/2018 | ||||||||
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| AuthorizedOfficialLastName: | CUSACK | ||||||||
| AuthorizedOfficialFirstName: | MICHELE | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT & CFO | ||||||||
| AuthorizedOfficialTelephone: | 5163216058 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320700000X | Y | Residential Treatment Facilities | Residential Treatment Facility, Physical Disabilities |
ID Information
| ID | Type | State | Issuer | Description | 1927311 | 05 | NY | MEDICAID |