Provider Demographics
NPI:1245364223
Name:MARY IMMACULATE HOSPITAL
Entity type:Organization
Organization Name:MARY IMMACULATE HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIR, PATHOLOGY DEPARTMENT
Authorized Official - Prefix:DR
Authorized Official - First Name:USHA
Authorized Official - Middle Name:C
Authorized Official - Last Name:RUDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:715-558-2714
Mailing Address - Street 1:152-11 89TH AVE.
Mailing Address - Street 2:MARY IMMACULATE HOSPITAL ,
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-1108
Mailing Address - Country:US
Mailing Address - Phone:718-558-2714
Mailing Address - Fax:718-558-2166
Practice Address - Street 1:24 NIGHT HERON DR
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-1108
Practice Address - Country:US
Practice Address - Phone:631-689-5654
Practice Address - Fax:718-558-2166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY115646282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG04463Medicare UPIN