Healthcare Provider Details

I. General information

NPI: 1669695797
Provider Name (Legal Business Name): LONG ISLAND COLLEGE HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 08/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

97 AMITY STREET
BROOKLYN NY
11201
US

IV. Provider business mailing address

97 AMITY STREET
BROOKLYN NY
11201
US

V. Phone/Fax

Practice location:
  • Phone: 718-780-4705
  • Fax: 718-780-1396
Mailing address:
  • Phone: 718-780-4705
  • Fax: 718-780-1396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number003327-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number003327 1
License Number StateNY

VIII. Authorized Official

Name: DR. VIJAY JOHN MANI
Title or Position: CHAIRMAN, ORTHOPEDICS DEPT.
Credential: MD
Phone: 718-780-4705