Provider Demographics
NPI:1043650625
Name:NSLIJ SOUTHSIDE HOSPITAL
Entity Type:Organization
Organization Name:NSLIJ SOUTHSIDE HOSPITAL
Other - Org Name:NSLIJ
Other - Org Type:Other Name
Authorized Official - Title/Position:NURSE PRACTIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:UNDARI-SCHWARTZ
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE PRACTIONER
Authorized Official - Phone:516-330-1578
Mailing Address - Street 1:301 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-8408
Mailing Address - Country:US
Mailing Address - Phone:631-968-3000
Mailing Address - Fax:
Practice Address - Street 1:301 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8408
Practice Address - Country:US
Practice Address - Phone:631-968-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-27
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY306519313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility