Basic Information
| Provider Information | |||||||||
| NPI: | 1275958050 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH SHORE LIJ HEALTH SYSTEM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 221 SPORTSMANS AVE | ||||||||
| Address2: | |||||||||
| City: | FREEPORT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115205635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165474930 | ||||||||
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| Practice Location | |||||||||
| Address1: | 27005 76TH AVE | ||||||||
| Address2: | |||||||||
| City: | NEW HYDE PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110401402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184707000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2014 | ||||||||
| LastUpdateDate: | 03/03/2014 | ||||||||
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| AuthorizedOfficialLastName: | NILES | ||||||||
| AuthorizedOfficialFirstName: | CAROLYN | ||||||||
| AuthorizedOfficialMiddleName: | BLAIR | ||||||||
| AuthorizedOfficialTitleorPosition: | NP | ||||||||
| AuthorizedOfficialTelephone: | 5165474930 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MS, FNP-C | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | F3382311 | NY | Y | Hospitals | General Acute Care Hospital |
No ID Information.