Provider Demographics
NPI:1316041924
Name:MARY IMMACULATE HOSPITAL
Entity Type:Organization
Organization Name:MARY IMMACULATE HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING DEPARTMENT
Authorized Official - Prefix:
Authorized Official - First Name:MARINA
Authorized Official - Middle Name:
Authorized Official - Last Name:ADELMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-743-7090
Mailing Address - Street 1:15211 89TH AVE
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-3730
Mailing Address - Country:US
Mailing Address - Phone:718-743-7090
Mailing Address - Fax:
Practice Address - Street 1:11449 SUTPHIN BLVD
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-1022
Practice Address - Country:US
Practice Address - Phone:718-558-6622
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0268521223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYT50266Medicare UPIN