Basic Information
| Provider Information | |||||||||
| NPI: | 1013514298 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MOUNT SINAI COMMUNITY FOUNDATION DBA SINAI MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26460 NETWORK PL | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606731264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732572820 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1500 S FAIRFIELD AVE FL 4 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606081782 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732571165 | ||||||||
| FaxNumber: | 7732571186 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2020 | ||||||||
| LastUpdateDate: | 10/01/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CARNEY | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SINAI MEDICAL GROUP PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7732575771 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MOUNT SINAI COMMUNITY FOUDATION | ||||||||
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| NPICertificationDate: | 10/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.