Provider Demographics
NPI:1033791058
Name:SOUTHSIDE FACULTY MEDICAL AFFILIATES UNIVERSITY FACULTY PRAC
Entity Type:Organization
Organization Name:SOUTHSIDE FACULTY MEDICAL AFFILIATES UNIVERSITY FACULTY PRAC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VICE PRESIDENT & CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:L
Authorized Official - Last Name:CUSACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-321-6058
Mailing Address - Street 1:2000 MARCUS AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1069
Mailing Address - Country:US
Mailing Address - Phone:516-266-3456
Mailing Address - Fax:516-266-3490
Practice Address - Street 1:1220 HICKSVILLE RD
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:NY
Practice Address - Zip Code:11783-1604
Practice Address - Country:US
Practice Address - Phone:516-266-3456
Practice Address - Fax:516-266-3490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-28
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Multi-Specialty