Basic Information
| Provider Information | |||||||||
| NPI: | 1346908662 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 E 42ND ST FL 2 | ||||||||
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| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100175612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6466058119 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1468 MADISON AVE | ||||||||
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| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100296508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2122416500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2021 | ||||||||
| LastUpdateDate: | 12/03/2021 | ||||||||
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| AuthorizedOfficialLastName: | PETERSON | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR DIRECTOR, CBO | ||||||||
| AuthorizedOfficialTelephone: | 6466058145 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 11/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.