Provider Demographics
NPI:1093723488
Name:LONG ISLAND JEWISH MEDICAL CENTER
Entity Type:Organization
Organization Name:LONG ISLAND JEWISH MEDICAL CENTER
Other - Org Name:END STAGE RENAL DIALYSIS FACILITY
Other - Org Type:Other Name
Authorized Official - Title/Position:SENIOR VICE PRESIDENT & CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:CUSACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-321-6058
Mailing Address - Street 1:972 BRUSH HOLLOW RD
Mailing Address - Street 2:5TH FLOOOR FINANCE
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-1740
Mailing Address - Country:US
Mailing Address - Phone:516-876-6000
Mailing Address - Fax:516-876-6600
Practice Address - Street 1:22022 HILLSIDE AVENUE
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11427-2020
Practice Address - Country:US
Practice Address - Phone:516-876-6000
Practice Address - Fax:516-876-6600
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LONG ISLAND JEWISH MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-03
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7003004H261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY333503Medicare Oscar/Certification