Healthcare Provider Details

I. General information

NPI: 1972941953
Provider Name (Legal Business Name): NORTH SHORE - LIJ CARDIOLOGY AT DEER PARK PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2013
Last Update Date: 07/26/2022
Certification Date: 07/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 DEER PARK AVE
DEER PARK NY
11729-5210
US

IV. Provider business mailing address

972 BRUSH HOLLOW RD FINANCE 5TH FLOOR
WESTBURY NY
11590-1740
US

V. Phone/Fax

Practice location:
  • Phone: 631-242-6166
  • Fax: 631-242-0728
Mailing address:
  • Phone: 516-876-6065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. MICHELE CUSAK
Title or Position: CFO
Credential:
Phone: 516-465-8162