Healthcare Provider Details

I. General information

NPI: 1275447716
Provider Name (Legal Business Name): GOOD SAMARITAN UNIVERSITY HOSPITAL- ST. CHARLES CAMPUS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 BELLE TERRE RD
PORT JEFFERSON NY
11777-1928
US

IV. Provider business mailing address

PO BOX 95000-6540
PHILADELPHIA PA
19195-0001
US

V. Phone/Fax

Practice location:
  • Phone: 631-474-6000
  • Fax:
Mailing address:
  • Phone: 631-465-6121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: LORRAINE HUMMEL
Title or Position: VP, PHYSICIAN ENTERPRISE FINANCIAL
Credential:
Phone: 631-465-6001