Healthcare Provider Details

I. General information

NPI: 1780142778
Provider Name (Legal Business Name): MT SINAI PEDIATRIC CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2019
Last Update Date: 04/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2653 W OGDEN AVE
CHICAGO IL
60608
US

IV. Provider business mailing address

1900 W POLK ST STE 220C
CHICAGO IL
60612-3723
US

V. Phone/Fax

Practice location:
  • Phone: 773-522-2010
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: SCOTT ANDRLE
Title or Position: DIRECTOR OF MANAGED CARE OPERATIONS
Credential:
Phone: 312-864-4649