MEDICARE: STATEN ISLAND UNIVERSITY HOSPITAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	282N00000X	General Acute Care Hospital		NY

General Provider Information

NPI Number	:	1477815520
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATEN ISLAND UNIVERSITY HOSPITAL

Provider Business Mailing Address
First Line	:	227 KOCH BLVD
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10312-5416
Country	:	US
Telephone Number	:	917-655-6207
Fax Number	:

Provider Business Practice Location Address
First Line	:	227 KOCH BLVD
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10312-5416
Country	:	US
Telephone Number	:	917-655-6207
Fax Number	:

Authorized Official
Title or Position	:	PGY-1
Name	:	OTAR DATAN
Credential	:	MD
Telephone Number	:	917-655-6207

Provider Enumeration Date	:	06/14/2012
Last Update Date	:	06/14/2012

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