Basic Information
| Provider Information | |||||||||
| NPI: | 1124497912 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI | ||||||||
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| OtherOrganizationName: | CARDIOVASCULAR SURGERY DEPARTMENT OF MOUNT SINAI SLR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 EAST 42ND STREET | ||||||||
| Address2: | 10TH FLOOR | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6466058119 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1111 AMSTERDAM AVENUE | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2125234000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2015 | ||||||||
| LastUpdateDate: | 09/22/2015 | ||||||||
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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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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 208G00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
No ID Information.