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General NPI Number Information
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NPI Number | 1881650869
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Entity Type | Organization
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Legal Business Name | SOUTHSIDE HOSPITAL DEPARTMENT OF PSYCHIATRY
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Dates
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Enumeration Date | 04/26/2006
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Last Update Date | 08/13/2008
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Provider Practice Location Address
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Address Line | 301 E MAIN ST
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City | BAY SHORE
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State | NY
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Zip | 11706-8408
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Country | US
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Telephone | 631-675-4149
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Fax |
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Provider Business Mailing Address
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Address Line | 301 E MAIN ST
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City | BAY SHORE
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State | NY
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Zip | 11706-8408
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Country | US
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Telephone | 631-675-4149
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MS. WINIFRED B. MACK
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Credential |
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Telephone | 631-968-9000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2084P0805X
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Taxonomy Name | Geriatric Psychiatry Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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