Basic Information
| Provider Information | |||||||||
| NPI: | 1689819971 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOUNT SINAI SCHOOL OF MEDICINE | ||||||||
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| OtherOrganizationName: | ELMHURST DIALYSIS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 GUSTAVE LEVY PLACE | ||||||||
| Address2: | BOX 3000 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100296574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2129873100 | ||||||||
| FaxNumber: | 2127315210 | ||||||||
| Practice Location | |||||||||
| Address1: | 7901 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | ELMHURST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113731329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183344000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2008 | ||||||||
| LastUpdateDate: | 10/13/2009 | ||||||||
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| AuthorizedOfficialLastName: | JABS | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | M.B.A. CEO FPA ASSOCIATES | ||||||||
| AuthorizedOfficialTelephone: | 2122414739 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
No ID Information.