Healthcare Provider Details

I. General information

NPI: 1467842393
Provider Name (Legal Business Name): LONG ISLAND JEWISH MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2015
Last Update Date: 01/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7559 263RD STREET @ 74TH AVENUE
GLEN OAKS NY
11004-1050
US

IV. Provider business mailing address

7559 263RD ST
GLEN OAKS NY
11004-1150
US

V. Phone/Fax

Practice location:
  • Phone: 718-470-4834
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code282NC2000X
TaxonomyChildren's Hospital
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL DWYER
Title or Position: ASSOCIATE EXECUTIVE DIRECTOR
Credential:
Phone: 718-470-3521