Basic Information
Provider Information | |||||||||
NPI: | 1487016507 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MOUNT SINAI DOCTORS LIHA | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 200 OLD COUNTRY RD | ||||||||
Address2: | SUITE 278 | ||||||||
City: | MINEOLA | ||||||||
State: | NY | ||||||||
PostalCode: | 115014235 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5168770977 | ||||||||
FaxNumber: | 5162946861 | ||||||||
Practice Location | |||||||||
Address1: | 200 OLD COUNTRY RD | ||||||||
Address2: | SUITE 278 | ||||||||
City: | MINEOLA | ||||||||
State: | NY | ||||||||
PostalCode: | 115014235 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5168770977 | ||||||||
FaxNumber: | 5162946861 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/28/2016 | ||||||||
LastUpdateDate: | 03/28/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GRESHAM | ||||||||
AuthorizedOfficialFirstName: | ALICIA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP OF NETWORK OPERATIONS | ||||||||
AuthorizedOfficialTelephone: | 2126599038 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | MOUNT SINAI HOSPITAL | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RE0101X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207RN0300X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 208800000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |   | 207RC0000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.