Provider Demographics
NPI:1912925199
Name:STATEN ISLAND UNIVERSITY HOSPITAL
Entity Type:Organization
Organization Name:STATEN ISLAND UNIVERSITY HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SVP AND CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:CUSACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-321-6058
Mailing Address - Street 1:475 SEAVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-3436
Mailing Address - Country:US
Mailing Address - Phone:718-226-4502
Mailing Address - Fax:718-226-4875
Practice Address - Street 1:475 SEAVIEW AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-3436
Practice Address - Country:US
Practice Address - Phone:718-226-4502
Practice Address - Fax:718-226-4875
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATEN ISLAND UNIVERSITY HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-17
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7004003H273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ330860OtherBLUE CROSS PSYCH
NY000881OtherBLUE CROSS PSYCH
NY00244202Medicaid
NY00244202Medicaid