Basic Information
| Provider Information | |||||||||
| NPI: | 1952538498 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOUNT SINAI SCHOOL OF MEDICINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 GUSTAVE L LEVY PL | ||||||||
| Address2: | BOX 1200 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100296500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2126598060 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5 E 98TH ST | ||||||||
| Address2: | 12TH FLOOR | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100296501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2126598060 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2009 | ||||||||
| LastUpdateDate: | 06/11/2009 | ||||||||
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| AuthorizedOfficialLastName: | RUSSO | ||||||||
| AuthorizedOfficialFirstName: | LOUIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR FPA | ||||||||
| AuthorizedOfficialTelephone: | 2122416228 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080T0004X | 204705 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Transplant Hepatology |
ID Information
| ID | Type | State | Issuer | Description | 01365306 | 05 | NY | MEDICAID |