Basic Information
Provider Information | |||||||||
NPI: | 1609120674 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MOUNT SINAI ELMHURST FACULTY PRACTICE GROUP | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GONZALEZ JIMENEZ | ||||||||
AuthorizedOfficialFirstName: | 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 | 207W00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |   | 208800000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |   | 207X00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
No ID Information.