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General NPI Number Information
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NPI Number | 1245364223
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Entity Type | Organization
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Legal Business Name | MARY IMMACULATE HOSPITAL
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Dates
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Enumeration Date | 03/14/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 24 NIGHT HERON DR
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City | STONY BROOK
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State | NY
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Zip | 11790-1108
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Country | US
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Telephone | 631-689-5654
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Fax | 718-558-2166
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Provider Business Mailing Address
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Address Line | 152-11 89TH AVE. MARY IMMACULATE HOSPITAL ,
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City | JAMAICA
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State | NY
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Zip | 11432-1108
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Country | US
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Telephone | 718-558-2714
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Fax | 718-558-2166
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Authorized Official
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Title or Position | CHAIR, PATHOLOGY DEPARTMENT
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Name | DR. USHA C RUDER
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Credential | M.D.
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Telephone | 715-558-2714
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 282NC0060X
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Taxonomy Name | Critical Access Hospital
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License Number | 115646
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License Number State | NY
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