Provider Demographics
NPI:1154504132
Name:LICH FACULTY PRACTICE
Entity type:Organization
Organization Name:LICH FACULTY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:HACKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-256-3424
Mailing Address - Street 1:160 WATER ST
Mailing Address - Street 2:20TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10038-4922
Mailing Address - Country:US
Mailing Address - Phone:212-256-3424
Mailing Address - Fax:
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:718-780-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-12
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWZZXW1Medicare PIN