Basic Information
| Provider Information | |||||||||
| NPI: | 1295965598 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOUNT SINAI SCHOOL OF MEDICINE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MOUNT SINAI ELMHURST FACULTY PRACTICE GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7901 BROADWAY | ||||||||
| Address2: | ROOM A1-9 | ||||||||
| City: | ELMHURST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113731329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183344952 | ||||||||
| FaxNumber: | 7183344815 | ||||||||
| Practice Location | |||||||||
| Address1: | 7901 BROADWAY | ||||||||
| Address2: | ROOM A1-9 | ||||||||
| City: | ELMHURST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113731329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183344952 | ||||||||
| FaxNumber: | 7183344815 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2009 | ||||||||
| LastUpdateDate: | 11/14/2012 | ||||||||
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| AuthorizedOfficialLastName: | BREWER | ||||||||
| AuthorizedOfficialFirstName: | MARLON | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7183342490 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207QG0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | 207QA0401X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine | 207QA0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Adolescent Medicine | 207QA0505X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine | 207QB0002X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Bariatric Medicine | 207QH0002X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Hospice and Palliative Medicine | 207QS1201X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sleep Medicine | 207QS0010X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207RG0300X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
No ID Information.