Provider Demographics
NPI:1700480050
Name:STATEN ISLAND UNIVERSITY HOSPITAL
Entity Type:Organization
Organization Name:STATEN ISLAND UNIVERSITY HOSPITAL
Other - Org Name:OPIOID TREATMENT PROGRAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VICE PRESIDENT & CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:L
Authorized Official - Last Name:CUSACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-321-6058
Mailing Address - Street 1:392 SEGUINE AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10309-3906
Mailing Address - Country:US
Mailing Address - Phone:718-226-3815
Mailing Address - Fax:718-226-8144
Practice Address - Street 1:392 SEGUINE AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10309-3906
Practice Address - Country:US
Practice Address - Phone:718-226-3815
Practice Address - Fax:718-226-8144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-27
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadoneGroup - Multi-Specialty