Healthcare Provider Details

I. General information

NPI: 1528025459
Provider Name (Legal Business Name): SOUTHSIDE HOSPITAL EMERGENCY DEPARTMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 10/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 E MAIN ST
BAY SHORE NY
11706-8408
US

IV. Provider business mailing address

301 E MAIN ST
BAY SHORE NY
11706-8408
US

V. Phone/Fax

Practice location:
  • Phone: 631-675-4149
  • Fax:
Mailing address:
  • Phone: 631-675-4149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: MS. WINIFRED MACK
Title or Position: CFO
Credential:
Phone: 631-968-9000