Healthcare Provider Details

I. General information

NPI: 1417343591
Provider Name (Legal Business Name): MOUNT SINAI COMMUNITY FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2015
Last Update Date: 04/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2653 W OGDEN AVE 2ND FLOOR
CHICAGO IL
60608-1647
US

IV. Provider business mailing address

1501 S CALIFORNIA AVE NR6-119
CHICAGO IL
60608-1732
US

V. Phone/Fax

Practice location:
  • Phone: 773-257-6840
  • Fax:
Mailing address:
  • Phone: 773-257-2905
  • Fax: 773-257-1788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN VAZQUEZ
Title or Position: CMO
Credential: MD
Phone: 773-257-6850