NPIMap

Organization Active NPI

Long Island Select Healthcare, Inc.

Doing business as LISH, Inc.

  • Federally Qualified Health Center (FQHC)
  • Port Jefferson Station, NY
National Provider Identifier
1417300575
Registry record updated Sep 27, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
LONG ISLAND SELECT HEALTHCARE, INC.
Doing business as
LISH, Inc.
Practice address
33 Terryville Rd
Port Jefferson Station, NY 11776-1331
Phone
(631) 650-2510
Fax
(631) 650-0497
NPI assigned
Jul 13, 2016
Last updated
Sep 27, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 27, 2019

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
James Powell, MD
Title
Ceo
Phone
(631) 650-2085

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

33 Terryville Rd
Port Jefferson Station, NY 11776-1331

Mailing address

159 Carleton Ave
Central Islip, NY 11722-4172
Phone (631) 650-2510

Other names 1

  • LISH, Inc. Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NY2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20161229000247 NY Part B Supplier - Clinic/Group Practice 5991086225 Receives reassigned benefits from 74 practitioners
11 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Smithtown, NY; Central Islip, NY; Riverhead, NY; Port Jefferson Station, NY; Manorville, NY; Hauppauge, NY; Center Moriches, NY
O20170216000525 NY Part A Provider - Federally Qualified Health Center (FQHC) 5991086225 Practice locations: Port Jefferson Station, NY

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1417300575. Details of each certification follow.

Federally qualified health center certification: CCN 571062

Legal name
LONG ISLAND SELECT HEALTHCARE, INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Feb 27, 2017
Last certification
Feb 27, 2017
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
May 12, 2014 in NY
Enrollment address
509 Route 112
Port Jefferson Station, NY 11776-1006

Other NPIs with the same Medicare PAC ID 5

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 11

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Lish Inc11 organizations share this tax ID, including this one

Other organizations with this tax ID 10

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 3

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
John Lessard Individual Corporate OfficerBoard Member-President May 9, 2016
Robert S Bud Individual Corporate OfficerBoard Member-Secretary May 9, 2014
Lois Stoddard Individual Corporate OfficerChief Financial Officer Apr 24, 2023
Corporate DirectorChief Financial Officer Apr 24, 2023
W-2 Managing EmployeeChief Financial Officer Apr 24, 2023

Practitioners & affiliated clinicians

Practitioners 11

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1468368000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1569542400000",
    "number": "1417300575",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "159 CARLETON AVE",
            "city": "CENTRAL ISLIP",
            "state": "NY",
            "postal_code": "117224172",
            "telephone_number": "631-650-2510",
            "fax_number": "631-650-0497"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "33 TERRYVILLE RD",
            "city": "PORT JEFFERSON STATION",
            "state": "NY",
            "postal_code": "117761331",
            "telephone_number": "631-650-2510",
            "fax_number": "631-650-0497"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LONG ISLAND SELECT HEALTHCARE, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-07-13",
        "last_updated": "2019-09-27",
        "status": "A",
        "authorized_official_last_name": "POWELL",
        "authorized_official_first_name": "JAMES",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "631-650-2085",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "LISH, Inc.",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Port Jefferson Station, NY

Sources for this page

Verify at the official NPI Registry.