Basic Information
Provider Information | |||||||||
NPI: | 1972513646 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MOUNT SINAI SCHOOL OF MEDICINE OF NEW YORK UNIVERSITY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MOUNT SINAI SCHOOL OF MEDICINE OB GYN ASSOCIATES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5 E 98TH ST | ||||||||
Address2: | BOX 1170 | ||||||||
City: | NEW YORK | ||||||||
State: | NY | ||||||||
PostalCode: | 100296501 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2122418470 | ||||||||
FaxNumber: | 2122413023 | ||||||||
Practice Location | |||||||||
Address1: | 1176 5TH AVE | ||||||||
Address2: | E LEVEL | ||||||||
City: | NEW YORK | ||||||||
State: | NY | ||||||||
PostalCode: | 100296503 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2126598557 | ||||||||
FaxNumber: | 2123692385 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/08/2006 | ||||||||
LastUpdateDate: | 10/12/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BERDEBES | ||||||||
AuthorizedOfficialFirstName: | DENISE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 2122415423 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
No ID Information.