Provider Demographics
NPI:1649305228
Name:SOUTHSIDE HOSPITAL DEPARTMENT OF CARDIOLOGY
Entity type:Organization
Organization Name:SOUTHSIDE HOSPITAL DEPARTMENT OF CARDIOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:WINIFRED
Authorized Official - Middle Name:B
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-968-3000
Mailing Address - Street 1:301 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-8408
Mailing Address - Country:US
Mailing Address - Phone:631-968-3000
Mailing Address - Fax:
Practice Address - Street 1:301 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8408
Practice Address - Country:US
Practice Address - Phone:631-968-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHSIDE HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-22
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW75831Medicare PIN