Provider Demographics
NPI:1619275625
Name:SUNY HEALTH SCIENCE CENTER AT BROOKLYN
Entity Type:Organization
Organization Name:SUNY HEALTH SCIENCE CENTER AT BROOKLYN
Other - Org Name:SUNY DMC@LICH-PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:
Authorized Official - Last Name:VIENTOS - SOTIRIADIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-270-2025
Mailing Address - Street 1:97 AMITY ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-6004
Mailing Address - Country:US
Mailing Address - Phone:718-780-1070
Mailing Address - Fax:
Practice Address - Street 1:97 AMITY ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-6004
Practice Address - Country:US
Practice Address - Phone:718-780-1070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-01
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
No2080I0007XAllopathic & Osteopathic PhysiciansPediatricsClinical & Laboratory ImmunologyGroup - Single Specialty
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Single Specialty
No2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Single Specialty
No2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care MedicineGroup - Single Specialty
No2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious DiseasesGroup - Single Specialty
No2080T0002XAllopathic & Osteopathic PhysiciansPediatricsMedical ToxicologyGroup - Single Specialty