Basic Information
| Provider Information | |||||||||
| NPI: | 1508333956 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOUNT SINAI SCHOOL OF MEDICINE | ||||||||
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| OtherOrganizationName: | MOUNT SINAI MARATHON MEDICAL - BEHAVIORAL HEALTH | ||||||||
| 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: | 175 FULTON AVE STE 309 | ||||||||
| Address2: | |||||||||
| City: | HEMPSTEAD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115503702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5164855710 | ||||||||
| FaxNumber: | 5164854225 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2018 | ||||||||
| LastUpdateDate: | 01/11/2019 | ||||||||
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| AuthorizedOfficialLastName: | GRESHAM | ||||||||
| AuthorizedOfficialFirstName: | ALICIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP NETWORK OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 2126599038 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 163WP0808X | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Psych/Mental Health | 363LP0808X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 2084P0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.