MEDICARE: NORTH SHORE MEDICAL GROUP OF MT SINAI SCHOOL OF MEDICINE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1003121013
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTH SHORE MEDICAL GROUP OF MT SINAI SCHOOL OF MEDICINE

Provider Business Mailing Address
First Line	:	201 PORTION RD
Second Line	:	SUITE C
City	:	LAKE RONKONKOMA
State	:	NY
Zip	:	11779-4172
Country	:	US
Telephone Number	:	631-585-5959
Fax Number	:

Provider Business Practice Location Address
First Line	:	201 PORTION RD
Second Line	:	SUITE C
City	:	LAKE RONKONKOMA
State	:	NY
Zip	:	11779-4172
Country	:	US
Telephone Number	:	631-585-5959
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	JANET STREET
Credential	:
Telephone Number	:	631-351-3703

Provider Enumeration Date	:	08/13/2010
Last Update Date	:	08/13/2010

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