Healthcare Provider Details

I. General information

NPI: 1104471622
Provider Name (Legal Business Name): MOUNT SINAI COMMUNITY FOUNDATION DBA SINAI MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2019
Last Update Date: 08/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

645 S CENTRAL AVE FL 6
CHICAGO IL
60644-5059
US

IV. Provider business mailing address

1501 S CALIFORNIA AVE NR 7-130
CHICAGO IL
60608
US

V. Phone/Fax

Practice location:
  • Phone: 773-854-5328
  • Fax: 773-854-5587
Mailing address:
  • Phone: 773-257-2905
  • Fax: 773-257-1788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DEBORAH CAPUTO
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 773-257-2905