Basic Information
| Provider Information | |||||||||
| NPI: | 1316986359 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MOUNT SINAI SCHOOL OF MEDICINE | ||||||||
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| OtherOrganizationName: | MOUNT SINAI DERMATOPATHOLOGY SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1428 MADISON AVE | ||||||||
| Address2: | ATRAN 610 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100296508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2122416064 | ||||||||
| FaxNumber: | 2122417832 | ||||||||
| Practice Location | |||||||||
| Address1: | 1428 MADISON AVE | ||||||||
| Address2: | ATRAN 610 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100296508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2122416064 | ||||||||
| FaxNumber: | 2122417832 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2006 | ||||||||
| LastUpdateDate: | 10/21/2009 | ||||||||
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| AuthorizedOfficialLastName: | JABS | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICIER | ||||||||
| AuthorizedOfficialTelephone: | 2122416228 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MOUNT SINAI SCHOOL OF MEDICINE | ||||||||
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| AuthorizedOfficialCredential: | M.D., MBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZD0900X | CLIA 33D1051889 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Dermatopathology |
No ID Information.