Basic Information
Provider Information | |||||||||
NPI: | 1396212445 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MOUNT SINAI SCHOOL OF MEDICINE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MOUNT SINAI MARATHON MEDICAL -NEONATES/PEDIATRICS | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8 N OCEANSIDE RD | ||||||||
Address2: |   | ||||||||
City: | ROCKVILLE CENTRE | ||||||||
State: | NY | ||||||||
PostalCode: | 115705125 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5166323670 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 8 N OCEANSIDE RD | ||||||||
Address2: |   | ||||||||
City: | ROCKVILLE CENTRE | ||||||||
State: | NY | ||||||||
PostalCode: | 115705125 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5166323670 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/26/2018 | ||||||||
LastUpdateDate: | 01/11/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GRESHAM | ||||||||
AuthorizedOfficialFirstName: | ALICIA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP NETWORK OPERATIONS | ||||||||
AuthorizedOfficialTelephone: | 2126599038 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   | 2080P0202X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology | 208M00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |   | 2080N0001X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
No ID Information.