Provider Demographics
NPI:1679696330
Name:MARY IMMACULATE HOSPITAL
Entity Type:Organization
Organization Name:MARY IMMACULATE HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIPERSON
Authorized Official - Prefix:DR
Authorized Official - First Name:USHA
Authorized Official - Middle Name:C
Authorized Official - Last Name:RUDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-558-2701
Mailing Address - Street 1:45 BARRYPARK CT
Mailing Address - Street 2:
Mailing Address - City:ALBERTSON
Mailing Address - State:NY
Mailing Address - Zip Code:11507-1501
Mailing Address - Country:US
Mailing Address - Phone:516-741-5465
Mailing Address - Fax:
Practice Address - Street 1:15211 89TH AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-3730
Practice Address - Country:US
Practice Address - Phone:718-558-2701
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY181564282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF33948Medicare UPIN