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General NPI Number Information
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NPI Number | 1679696330
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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 | 04/09/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 15211 89TH AVE
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City | JAMAICA
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State | NY
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Zip | 11432-3730
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Country | US
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Telephone | 718-558-2701
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Fax |
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Provider Business Mailing Address
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Address Line | 45 BARRYPARK CT
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City | ALBERTSON
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State | NY
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Zip | 11507-1501
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Country | US
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Telephone | 516-741-5465
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Fax |
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Authorized Official
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Title or Position | CHAIPERSON
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Name | DR. USHA C RUDER
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Credential |
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Telephone | 718-558-2701
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 282N00000X
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Taxonomy Name | General Acute Care Hospital
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License Number | 181564
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License Number State | NY
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