Healthcare Provider Details

I. General information

NPI: 1437333184
Provider Name (Legal Business Name): LICH FACULTY PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2007
Last Update Date: 04/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

339 HICKS ST
BROOKLYN NY
11201-5509
US

IV. Provider business mailing address

160 WATER ST 20TH FLOOR
NEW YORK NY
10038-4922
US

V. Phone/Fax

Practice location:
  • Phone: 718-780-1000
  • Fax:
Mailing address:
  • Phone: 212-256-3424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: DEBORAH HACKETT
Title or Position: AVP
Credential:
Phone: 212-256-3424