Basic Information
| Provider Information | |||||||||
| NPI: | 1689947160 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI | ||||||||
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| OtherOrganizationName: | GERIATRIC MEDICINE DEPARTMENT OF MOUNT SINAI | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 28082 | ||||||||
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| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100871008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2129873100 | ||||||||
| FaxNumber: | 6466053029 | ||||||||
| Practice Location | |||||||||
| Address1: | 1440 MADISON AVE | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100296508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2126588552 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2012 | ||||||||
| LastUpdateDate: | 06/24/2015 | ||||||||
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| AuthorizedOfficialLastName: | MACNEILL | ||||||||
| AuthorizedOfficialFirstName: | CRYSTAL | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT, CBO DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6466058112 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0002X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine | 207RG0300X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
No ID Information.