Provider Demographics
NPI:1003863820
Name:LONG ISLAND COLLEGE HOSPITAL
Entity Type:Organization
Organization Name:LONG ISLAND COLLEGE HOSPITAL
Other - Org Name:MEDICINE SPECIALTY GROUP AT LICH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING EMPLOYEE
Authorized Official - Prefix:
Authorized Official - First Name:VLADIMIR
Authorized Official - Middle Name:
Authorized Official - Last Name:PRIVMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-780-2155
Mailing Address - Street 1:160 WATER ST
Mailing Address - Street 2:20FL
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10038-4922
Mailing Address - Country:US
Mailing Address - Phone:212-256-3682
Mailing Address - Fax:212-256-3538
Practice Address - Street 1:97 AMITY ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-6004
Practice Address - Country:US
Practice Address - Phone:718-780-2155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02420102Medicaid
WEN051Medicare ID - Type Unspecified