Healthcare Provider Details

I. General information

NPI: 1780022772
Provider Name (Legal Business Name): NORTH SHORE LIJ OB GYN AT GARDEN CITY 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

877 STEWART AVE SUITE 7
GARDEN CITY NY
11530-4803
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 516-622-2072
  • Fax: 516-222-2854
Mailing address:
  • Phone: 516-876-6065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State

VIII. Authorized Official

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