Provider Demographics
NPI:1144276627
Name:LONG ISLAND COLLEGE HOSPITAL UROLOGY ASSOCIATES AT LICH
Entity type:Organization
Organization Name:LONG ISLAND COLLEGE HOSPITAL UROLOGY ASSOCIATES AT LICH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:J
Authorized Official - Last Name:CASDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-780-1520
Mailing Address - Street 1:339 HICKS ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-5509
Mailing Address - Country:US
Mailing Address - Phone:718-780-1520
Mailing Address - Fax:718-780-1362
Practice Address - Street 1:339 HICKS ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-5509
Practice Address - Country:US
Practice Address - Phone:718-780-1520
Practice Address - Fax:718-780-1362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY154270-1208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02074959Medicaid
NYW35411Medicare PIN