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General NPI Number Information
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NPI Number | 1033791058
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Entity Type | Organization
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Legal Business Name | SOUTHSIDE FACULTY MEDICAL AFFILIATES UNIVERSITY FACULTY PRACTICE CORP
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Dates
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Enumeration Date | 04/28/2021
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Last Update Date | 01/06/2026
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Provider Practice Location Address
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Address Line | 1220 HICKSVILLE RD
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City | SEAFORD
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State | NY
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Zip | 11783-1604
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Country | US
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Telephone | 516-266-3456
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Fax | 516-266-3490
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Provider Business Mailing Address
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Address Line | 2000 MARCUS AVE
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City | NEW HYDE PARK
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State | NY
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Zip | 11042-1069
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Country | US
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Telephone | 516-266-3456
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Fax | 516-266-3490
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Authorized Official
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Title or Position | EXECUTIVE VICE PRESIDENT & CFO
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Name | MRS. MICHELE L CUSACK
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Credential |
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Telephone | 516-321-6058
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085B0100X
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Taxonomy Name | Body Imaging Physician
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License Number |
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License Number State |
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