Basic Information
| Provider Information | |||||||||
| NPI: | 1992131635 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GOOD SHEPHERD HOSPICE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GOOD SHEPHERD PHYSICIANS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 BI COUNTY BLVD | ||||||||
| Address2: | |||||||||
| City: | FARMINGDALE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117353943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6318287415 | ||||||||
| FaxNumber: | 6318287494 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 BI COUNTY BLVD | ||||||||
| Address2: | |||||||||
| City: | FARMINGDALE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117353943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6318287415 | ||||||||
| FaxNumber: | 6318287494 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2013 | ||||||||
| LastUpdateDate: | 09/25/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PAGE | ||||||||
| AuthorizedOfficialFirstName: | KERRIANNE | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF MEDICAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6314656300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GOOD SHEPHERD HOSPICE | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LH0002X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Hospice and Palliative Medicine |
No ID Information.