Basic Information
| Provider Information | |||||||||
| NPI: | 1841531795 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FPA HOSPITAL BASED | ||||||||
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| OtherOrganizationName: | MOUNT SINAI DERMATOPATHOLOGY SERVICES III | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1468 MADISON AVE | ||||||||
| Address2: | ANNENBERG 03-08 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100296508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2122416064 | ||||||||
| FaxNumber: | 2122417832 | ||||||||
| Practice Location | |||||||||
| Address1: | 1468 MADISON AVE | ||||||||
| Address2: | ANNENBERG 03-08 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100296508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2127317772 | ||||||||
| FaxNumber: | 2125347491 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2013 | ||||||||
| LastUpdateDate: | 03/02/2015 | ||||||||
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| AuthorizedOfficialLastName: | MACNEILL | ||||||||
| AuthorizedOfficialFirstName: | CRYSTAL | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP, CBO DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2122416228 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FPA HOSPITAL BASED | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MBA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZD0900X | CLIA 33D1051889 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Dermatopathology |
No ID Information.