Provider Demographics
NPI:1477815520
Name:STATEN ISLAND UNIVERSITY HOSPITAL
Entity Type:Organization
Organization Name:STATEN ISLAND UNIVERSITY HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PGY-1
Authorized Official - Prefix:
Authorized Official - First Name:OTAR
Authorized Official - Middle Name:
Authorized Official - Last Name:DATAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-655-6207
Mailing Address - Street 1:227 KOCH BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-5416
Mailing Address - Country:US
Mailing Address - Phone:917-655-6207
Mailing Address - Fax:
Practice Address - Street 1:227 KOCH BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-5416
Practice Address - Country:US
Practice Address - Phone:917-655-6207
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTH SHORE LIJ
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-06-14
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital