Basic Information
| Provider Information | |||||||||
| NPI: | 1629091921 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOUNT SINAI SCHOOL OF MEDICINE | ||||||||
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| OtherOrganizationName: | HEMATOLOGY ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 GUSTAVE LEVY PLACE BOX 3000 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100296574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2129873100 | ||||||||
| FaxNumber: | 2127315220 | ||||||||
| Practice Location | |||||||||
| Address1: | I GUSTAVE LEVY PLACE | ||||||||
| Address2: | RUTTENBERG TREATMENT CENTER | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100296574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2129873100 | ||||||||
| FaxNumber: | 2127315220 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 10/09/2009 | ||||||||
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| AuthorizedOfficialLastName: | JABS | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | M.B.A. CEO FPA ASSOCIATES | ||||||||
| AuthorizedOfficialTelephone: | 2122414739 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RH0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology |
ID Information
| ID | Type | State | Issuer | Description | 01175924 | 05 | NY | MEDICAID |