Basic Information
| Provider Information | |||||||||
| NPI: | 1437641636 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI | ||||||||
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| OtherOrganizationName: | MOUNT SINAI DOCTORS SOUTH NASSAU - NEONATES / PEDIATRICS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 HEALTHY WAY | ||||||||
| Address2: | |||||||||
| City: | OCEANSIDE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115721551 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 196 MERRICK RD | ||||||||
| Address2: | |||||||||
| City: | OCEANSIDE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5162558400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2018 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
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| AuthorizedOfficialLastName: | GRESHAM | ||||||||
| AuthorizedOfficialFirstName: | ALICIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OF NETWORK OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 2126599038 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0202X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology | 208000000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.