Healthcare Provider Details

I. General information

NPI: 1568898138
Provider Name (Legal Business Name): NORTH SHORE - LIJ INTERNAL MEDICINE AT LYNBROOK PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2013
Last Update Date: 07/25/2022
Certification Date: 07/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

158 HEMPSTEAD AVE
LYNBROOK NY
11563-1605
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 516-593-3541
  • Fax: 516-599-8307
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. MICHELE CUSAK
Title or Position: CFO
Credential:
Phone: 516-562-8182