Provider Demographics
NPI:1710122627
Name:LONG ISLAND COLLEGE HOSPITAL
Entity Type:Organization
Organization Name:LONG ISLAND COLLEGE HOSPITAL
Other - Org Name:REHAB UNIT
Other - Org Type:Other Name
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-256-3027
Mailing Address - Street 1:160 WATER ST
Mailing Address - Street 2:SUITE 2329
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10038-4922
Mailing Address - Country:US
Mailing Address - Phone:212-256-3027
Mailing Address - Fax:212-256-3595
Practice Address - Street 1:339 HICKS ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-5509
Practice Address - Country:US
Practice Address - Phone:212-256-3027
Practice Address - Fax:212-256-3595
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LONG ISLAND COLLEGE HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-12-05
Last Update Date:2008-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY700101H273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000060OtherBLUE C ROSS
NY00243678Medicaid
NY000060OtherBLUE C ROSS