Basic Information
| Provider Information | |||||||||
| NPI: | 1518211580 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MOUNT SINAI ELMHURST FACULTY PRACTICE GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 7901 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | ELMHURST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113731329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183341591 | ||||||||
| FaxNumber: | 7183344815 | ||||||||
| Practice Location | |||||||||
| Address1: | 7901 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | ELMHURST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113731329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183341591 | ||||||||
| FaxNumber: | 7183344815 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2012 | ||||||||
| LastUpdateDate: | 05/10/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | GONZALEZ JIMENEZ | ||||||||
| AuthorizedOfficialFirstName: | MARIA PILAR | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, FACULTY PRACTICE GROUP | ||||||||
| AuthorizedOfficialTelephone: | 7183341591 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080A0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | 2080N0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | 2080P0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology | 2080P0207X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Hematology-Oncology | 2080P0210X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Nephrology | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.