Attach to Form 990 or Form 990-EZ.
See separate instructions.| (i) Name of supported organization |
(ii) EIN |
(iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions)) |
(iv) Is the organization in col. (i) listed in your governing document? |
(v) Did you notify the organization in col. (i) of your support? |
(vi) Is the organization in col. (i) organized in the U.S.? |
(vii) Amount of support? |
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| Yes | No | Yes | No | Yes | No | ||||
| Total | |||||||||
| Calendar year(or fiscal year beginning in) | (a) 2007 | (b) 2008 | (c) 2009 | (d) 2010 | (e) 2011 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .... | ||||||
| 2 | Tax revenues levied for the organization's benefit and either paid to or expended on its behalf....... | ||||||
| 3 | The value of services or facilities furnished by a governmental unit to the organization without charge.. | ||||||
| 4 | Total. Add lines 1 through 3.. | ||||||
| 5 | The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f).. | ||||||
| 6 | Public Support. Subtract line 5 from line 4. | ||||||
| Calendar year(or fiscal year beginning in) | (a) 2007 | (b) 2008 | (c) 2009 | (d) 2010 | (e) 2011 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 7 | Amounts from line 4.. | ||||||
| 8 | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | ||||||
| 9 | Net income from unrelated business activities, whether or not the business is regularly carried on.. | ||||||
| 10 | Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets.. | ||||||
| 11 | Total support (Add lines 7 through 10). | ||||||






| Calendar year(or fiscal year beginning in) | (a) 2007 | (b) 2008 | (c) 2009 | (d) 2010 | (e) 2011 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") . | ||||||
| 2 | Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose...... | ||||||
| 3 | Gross receipts from activities that are not an unrelated trade or business under section 513.. | ||||||
| 4 | Tax revenues levied for the organization's benefit and either paid to or expended on its behalf... | ||||||
| 5 | The value of services or facilities furnished by a governmental unit to the organization without charge.. | ||||||
| 6 | Total. Add lines 1 through 5. | ||||||
| 7a | Amounts included on lines 1, 2, and 3 received from disqualified persons... | ||||||
| b | Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year. | ||||||
| c | Add lines 7a and 7b.. | ||||||
| 8 | Public Support (Subtract line 7c from line 6.) | ||||||
| Calendar year (or fiscal year beginning in) | (a) 2007 | (b) 2008 | (c) 2009 | (d) 2010 | (e) 2011 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 9 | Amounts from line 6... | ||||||
| 10a | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | ||||||
| b | Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975. | ||||||
| c | Add lines 10a and 10b. | ||||||
| 11 | Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on. | ||||||
| 12 | Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.) | ||||||
| 13 | Total support (Add lines 9, 10c, 11 and 12.). | ||||||




| Facts And Circumstances Test |
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| Explanation |
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Attach to Form 990 or 990-EZ.| Identifier | Return Reference | Explanation |
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| BOARD MEMBER RELATIONS | PART VI, SECTION A - GOVERNING BODY AND MANAGEMENT, LINE 2 | All transactions with North Shore-LIJ Health System entities are as follows: (1) negotiated at arm's length; (2) all purchases are at fair market value; and (3) all products or services are rendered on an "as needed" basis. William Achenbaum has a business relationship with Eric and Roger Blumencranz. John Alexander has a business relationship with John Shall and Stanley Applebaum. Philip Altheim has a business relationship with Eric Blumencranz. Stanley Applebaum has a business relationship with John Alexander and John Shall. Michael Ashner has a business relationship with William Mack. Morton Bass has a family relationship with Sandra Atlas Bass. Eric Blumencranz has as a family relationship with Roger Blumencranz. He has a business relationship with Roger Blumencranz, William Achenbaum, Philip Altheim, Richard D. Goldstein, Lloyd Goldman, Alan Greene, James Greene, Richard Guarasci, Richard Horowitz, Jeffrey Jurick, Lyn Jurick, Seth Kupferberg, Arthur Levine, Stuart Levine, David Mack, Bradley Marsh, Charles Merinoff, Ralph Nappi, Dennis Riese. Roger Blumencranz has a family relationship with Eric Blumencranz. He has a business relationship with Eric Blumencranz, William Achenbaum, Alan Greene, James Greene, Stanley Grey, Richard D. Goldstein, Richard Horowitz, Jeffrey Jurick, Lyn Jurick, Stuart Levine, David Mack, Bradley Marsh, Charles Merinoff, Ralph Nappi, Mark Solazzo, Donald Zucker, Barbara Zucker. David Blumenfeld has a family relationship with Edward Blumenfeld. Edward Blumenfeld has a family relationship with David Blumenfeld. He has a business relationship with William Mack. Steve Braun has a family relationship with Richard Sims. Alan Chopp has a business relationship with Patrick McDermott. Mark Claster has a business relationship with Robert Rosenthal, Richard Goldstein, Saul Katz. Philippe Dauman has a business relationship with Michael Hoffman. Daniel deRoulet has a family relationship with Lorinda deRoulet. Lorinda deRoulet has a family relationship with Daniel deRoulet. Leonard Feinstein has a business relationship with William Mack. Anthony Ferreri has a family and business relationship with John Shall. Lloyd Goldman has a business relationship with Eric Blumencranz, Richard Goldstein and William Mack. Richard D. Goldstein has a business relationship with Roger Blumencranz, Eric Blumencranz, Mark Claster, Lloyd Goldman, William Mack, and Barry Rubenstein. Joaquin Gonzalez has a business relationship with John Shall. Alan I. Greene has a family relationship with James R. Greene. He has a business relationship with Eric and Roger Blumencranz. James R. Greene has a family relationship with Alan I. Green. He has a business relationship with Eric and Roger Blumencranz. Stanley Grey has a business relationship with Roger Blumencranz. Richard Guarasci has a business relationship with Eric Blumencranz. Paul Guenther has a business relationship with Michael Hoffman. William Hiltz has a business relationship with Michael Hoffman and Jeff Maurer. Michael Hoffman has a business relationship with Phillipe Dauman, Paul Guenther, Marlene Hess, William Hiltz and Richard Nye. Richard Horowitz has a business relationship with Eric and Roger Blumencranz. Jeffrey Jurick has a family relationship with Lynn Jurick. He has a business relationship with Eric and Roger Blumencranz. Lynn Jurick has a family relationship with Jeffrey Jurick. She has a business relationship with Eric and Roger Blumencranz. David Katz has a family relationship with Saul Katz and Michael Katz. Michael Katz has a family relationship with Saul Katz and David Katz. He has a business relationship with Saul Katz, Curt Launer and Michael Slade. Saul Katz has a family relationship with Michael Katz and David Katz. He has a business relationship with Mark Claster, Michael Katz, Curt Launer and Michael Slade. Seth Kupferberg has a business relationship with Eric Blumencranz. Jeffrey Lane has a business relationship with William Mack. Curt Launer has a business relationship with Michael Katz. David Lehr has a business relationship with Ronald Mazzucco. Arthur Levine has a business relationship with Eric Blumencranz. Stuart Levine has a business relationship with Eric and Roger Blumencranz. David Mack has a family relationship with William Mack. He has a business relationship with William Mack, Eric Blumencranz, and Roger Blumencranz. William Mack has a family relationship with David Mack. He has business relationships with David Mack, Michael Ashner, Edward Blumenfeld, Leonard Feinstein, Lloyd Goldman, Jeffrey Lane, Barry Rubenstein, Scott Rudolph, Richard Goldstein and Roy Zuckerberg. Bradley Marsh has a family relationship with Jack Ross. He has a business relationship with Eric and Roger Blumencranz. Ronald Mazzucco has a business relationship with David Lehr. F.J. McCarthy has a business relationship with Robert Rosenthal. Patrick McDermott has a business relationship with Alan Chopp and John Shall. Charles Merinoff has a business relationship with Eric Blumencranz. Richard Murcott has a business relationship with Barry Rubenstein. Ralph Nappi has a business relationship with Eric Blumencranz. Dennis Riese has a business relationship with Eric Blumencranz. Robert Rosenthal has a business relationship with Mark Claster and F.J. McCarthy. Dr Bernard Rosof has a business relationship with Huntington Hospital Trustees. Jack Ross has a family relationship with Bradley Marsh. Barry Rubenstein has a business relationship with Richard Goldstein, William Mack and Mark Claster. Scott Rudolph has a business relationship with William Mack. John Shall has a family relationship with Anthony Ferreri. He has a business relationship with Anthony Ferreri, Patrick McDermott, John Alexander, Stanley Applebaum, and Joaquin Gonzalez. Richard Sims has a family relationship with Steve Braun. Michael Slade has a business relationship with Eric Blumencranz, Saul Katz and Michael Katz. Barbara Hrbek Zucker has a family relationship with Donald Zucker. She has a business relationship with Roger Blumencranz. Donald Zucker has a family relationship with Barbara Hrbek Zucker. He has a business relationship with Roger Blumencranz. Roy Zuckerberg has a business relationship with William Mack. |
| EXECUTIVE COMMITTEE | PART VI, SECTION B - POLICIES, LINE 11 | All North Shore-LIJ Health System Inc. and affiliated entities prepare the annual Return of Organization Exempt Form Income Tax (Form 990) with input from various departments including Corporate Compliance, Finance, Human Resources, and Legal. Before filing the returns, the documents are electronically made available for review to members of the Executive Committee. The Executive Committee, which is a committee made up of members from the Board of Trustees, may exercise all of the authority of the Board of Trustees except as such authority is limited by applicable law and except to the extent, if any, that such authority would be inconsistent with any provision of these By-laws or is limited by any resolution to such effect adopted by the Board of Trustees. |
| CONFLICTS OF INTEREST | PART VI, SECTION B - POLICIES, LINE 12C | The North Shore-Long Island Jewish Health System ("Health System") has several control mechanisms to mitigate conflicts of interest. The Health System's Code of Ethical Conduct contains a detailed section educating individuals about how to avoid potential conflicts of interest. Specifically, our Code of Ethical Conduct requires individuals to conduct Health System business in a manner that places the interests of the Health System ahead of their personal interests. In addition, the Health System has a Conflicts of Interest Policy Statement further elaborating upon individuals' disclosure and recusal obligations. Individuals that are in a position to influence the business or other decisions of the Health System are required to filled out a conflicts of interest disclosure form on a regular basis. The Corporate Compliance Office reviews all disclosures of possible conflicts, including matters disclosed in any conflicts of interest disclosure report and takes any actions deemed required or appropriate to manage or resolve any actual or potential conflicts of interest. In appropriate cases these disclosures and responsive actions will be reported to the Health System's Audit and Corporate Compliance Committee and other applicable committees. In addition, the Health System provides training to individuals on an annual basis regarding conflicts of interest and other compliance related topics. If an individual violates the Code of Ethical Conduct or any related policy such as the Conflicts of Interest Policy Statement, appropriate disciplinary action is taken based upon the facts and circumstances of the situation. |
| OFFICERS COMPENSATION | PART VI, SECTION B - POLICIES, LINE 15 | The by-laws of the Health System create a committee of the Board with full powers of the Board to review and approve the compensation of officers and other key employees. The committee consists of approximately 6 trustees who have no connection to the System except as trustees and they have no conflicts as to matters they consider. The committee meets several times a year as needed but always meets in November/December to review and determine officer and key employee compensation for the following year. For purposes of their review the committee considers the recommendations of the CEO for all persons other than the CEO. For purposes of the review each year the committee receives information from an outside independent compensation consultant as to compensation for comparable positions in comparable organizations and makes its decisions on this basis, with the overall objective of paying base salary at the 50th percentile. Any contracts or other compensation for officers or key employees are separately considered and normally only approved after receipt of a "fairness opinion" from the independent consultant. All the work and process of the committee is structured to fall within the applicable safe harbor regulations. |
| DISCLOSURES | PART VI, SECTION C - DISCLOSURES, LINE 19 | CURRTENTLY THE ORGANIZATION PROVIDES ITS GOVERNING DOCUMENTS, CONFLICTS OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. |
| NON-COMPENSATED TRUSTEES | PART VII, SECTION A - LINE 1A | Richard S. Abramson Albert L. Granger, DDS Katherine McEnroe William Achenbaum Alan I. Greene James McMullen John W. Alexander James R. Greene Charles Merinoff Ira I. Altfeder Stanley Grey Aimee Merszei Philip S. Altheim Richard Guarasci, PhD Richard D. Monti Stanley A. Applebaum Paul B. Guenther Tomas D. Morales, PhD Michael L. Ashner Henry L. Hackmann Richard Murcott Beverly VP. Banker Amy M. Hagedorn Ralph A. Nappi Ralph M. Baruch Stephen L. Hammerman Richard B. Nye Morton M. Bass Ira Hazan Clyde I. Payne, Ed.D. Frank J. Besignano Linda W. Heaney Arnold S. Penner Elise M. Bloom Marlene Hess John J. Raggio Eric S. Blumencranz William O. Hiltz Lewis S. Ranieri Roger A. Blumencranz Michael Hoffman Jay R. Raubvogel David Blumenfeld Gedale B. Horowitz Corey Ribotsky Edward Blumenfeld Richard A. Horowitz Dennis Riese E. Steve Braun M. Allan Hyman Terry P. Rifkin, M.D. Dayton T. Brown, Jr Mark Jacobson Robert A. Rosen Allen E. Busching Jeffrey Jurick Marcie Rosenberg Jonathan S. Canno Lyn Jurick Robert D. Rosenthal Michael Caridi Arthur Kalish Bernard M. Rosof, M.D. Rev. Carolina Sr, Ed.D Steven L. Kantor Jack J. Ross Rudolph C. Carryl David M. Katz Barry Rubenstein Robert W. Chasanoff Michael Katz Herbert Rubin Alan Chopp Saul B. Katz Scott Rudolph Mark Claster Lisa A. Kaufman Michael H. Sahn Diana F. Colgate Robert Kaufman Frank W. Scarangello, Sr. Daniel M. Crown Cary Kravet Norman Schlanger Philippe P. Dauman Stanley Kreitman Lois C. Schlissel Daniel C. de Roulet Seth Kupferberg John M. Shall Lorinda de Roulet Jeffrey B. Lane Robert F. Shapiro Thomas E. Dewey, Jr. Curt N. Launer Marc V. Shaw Thomas E. Dooley Laura Lauria Sean G. Simon Michael J. Dowling Kevin F. Lawlor Richard Sims Robert N. Downey Michale S. Leeds Michael C. Slade Melvin Dubin David W. Lehr Phyllis Hill Slater Patrick R. Edwards Jonathan W. Leigh Howard D. Stave Toni J. Elliott Sylvia Lester Russell Stern Michael A. Epstein Arthur S. Levine Maganlal Sutaria, M.D. Leonard Feinstein Stuart R. Levine John B. Thomson, Jr. Michael E. Feldman Seth Lipsay Peter Tilles Anthony C. Ferreri David S. Mack Sandra Tytel Arlene Lane Fisher William L. Mack Nancy Waldbaum Catherine C. Foster Howard S. Maier Gary Walter William H. Frazier Linda Manfredi Howard Weingrow Eugene B. Friedman, M.D.James S. Marcus Lewis M. Weston Sy Garfinkel Bradley Marsh, D.P.M. Jon A. Wurtzburger Lloyd Michael Goldman Jeffrey S. Maurer Barbara Hrbek Zucker Richard D. Goldstein Ronald J. Mazzucco Donald Zucker J. Joaquin Gonzalez F.J. McCarthy Roy J. Zuckerberg Michael Gould Patrick F. McDermott |
| AVERAGE HOURS | PART VII, SECTION A - LINE 1A, COLUMN (B) | This organization is affiliated with the North Shore Long Island Jewish Health System (the "Health System"). The Officers, Directors and Trustees listed on Schedule J hold similar positions with both this organization and other affiliates of the Health System, and they do not separately allocate their time to this organization and such other affiliates. The hours shown for all such persons reflect time devoted to the entire Health System and its affiliates, including this organization. For Directors and Trustees, the hours shown reflect the estimated average weekly time. For officers, Key Employees and Highest Compensated Employees, the hours shown reflect the weekly hours used when determining compensation payments for services rendered and are, generally, less than the actual weekly hours devoted to the Health System and its affiliates. |
| GOVERNING BODY | PART VI, LINE 7 | North Shore Long Island Jewish Health Care, Inc. ("Health Care") is the sole corporate member of the organization. Health Care has the right to elect or appoint members of the organization's governing body and has the right to approve or ratify certain corporate decisions. This organization and Health Care are part of the North Shore Long Island Jewish Health System, an integrated health care delivery system. |
| RECONCILIATION OF NET ASSETS | PART XI, LINE 5 | CHANGE IN NET UNREALIZED GAINS/LOSSES (5,407,624) DEFEASANCE OF LONG TERM DEBT (4,167,184) MEDICAL RESIDENT TAX RECOVERY 16,236 OTHER CHANGES IN NET ASSETS 54,000,000 CHANGE IN EQUITY UNDER FAS 136 13,593,113 NET ASSETS RELEASED (9,411) ADJ TO ACCRUAL OF AFFILIATES 10,391,621 TOTAL 68,416,751 |
| BY-LAW CHANGES | PART VI, SECTION A - GOVERNING BODY AND MANAGEMENT, LINE 4 | The By-Law changes makes the corporation a member of an obligated group for financing purposes, with other member-hospitals of the North Shore-Long Island Jewish Health System. |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:Richard D. Goldstein TITLE:Chairman HOURS:3 |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:William O. Hiltz TITLE:Chairman of Exec Committe HOURS:3 |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:Michael J. Dowling TITLE:President & CEO HOURS:50 |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:Mark Claster TITLE:Vice Chairman HOURS:2 |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:William L. Mack TITLE:Vice Chairman HOURS:2 |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:Barry Rubenstein TITLE:Vice Chairman HOURS:2 |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:Paul B. Guenther TITLE:Vice Chairman of Exec Com HOURS:2 |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:Marlene Hess TITLE:Vice Chairman of Exec Com HOURS:2 |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:Michael Hoffman TITLE:Treasurer HOURS:2 |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:Michael Gould TITLE:Assistant Treasurer HOURS:2 |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:Catherine C. Foster TITLE:Secretary HOURS:2 |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:Jim McMullen TITLE:Assistant Treasurer HOURS:2 |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:Lawrence G. Smith, MD TITLE:EVP, PHYSICIAN IN CHIEF HOURS:50 |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:Mark J. Solazzo TITLE:EVP & COO HOURS:50 |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:Howard B. Gold TITLE:SVP, Revenue & Business Dev HOURS:50 |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:Jeffrey A. Kraut TITLE:SVP, Planning HOURS:50 |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:Robert S. Shapiro TITLE:SVP/CFO HOURS:50 |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:Eugene S. Tangney TITLE:REGIONAL EXECUTIVE DIRECTOR HOURS:50 |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:Keith C. Thompson TITLE:SVP & General Counsel HOURS:50 |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:Harry E. Gindi TITLE:Assistant Secretary HOURS:38 |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:Ralph Nappi TITLE:TRUSTEE AND PRES. FOUNDATION HOURS:50 |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:Anthony C. Ferreri TITLE:TRUSTEE AND PRES/CEO SIUH HOURS:50 |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:Kevin F. Lawlor TITLE:TRUSTEE AND PRES/CEO HUNT HOSP HOURS:50 |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:NON-COMPENSATED TRUSTEES TITLE:SEE SCHEDULE O HOURS:2 |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:Philip Rosenthal TITLE:Executive Director HOURS:50 |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:FRANK DANZA TITLE:EXECUTIVE DIRECTOR HOURS:50 |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:ARTHUR KLEIN TITLE:REGIONAL EXECUTIVE DIRECTOR HOURS:50 |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:Mitchell Roslin MD TITLE:Director - Obesity Surgery HOURS:50 |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:Paresh Shah MD TITLE:Chief Laparoscopic Surgery HOURS:50 |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:Richard Green MD TITLE:Chairman - Dept of Surgery HOURS:50 |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:Vicken Pamoukian MD TITLE:Director - Endovascular Surg HOURS:50 |
| HOURS DEVOTED FOR RELATED ORGANIZATION | FORM 990 PART VII | NAME:JACK ANSELL TITLE:CHAIR, DEPT OF MEDICINE HOURS:50 |
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