Healthcare Provider Details

I. General information

NPI: 1801818570
Provider Name (Legal Business Name): MOUNT SINAI COMMUNITY FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 05/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1239 W 18TH ST
CHICAGO IL
60608-3242
US

IV. Provider business mailing address

1501 S CALIFORNIA AVE
CHICAGO IL
60608-1732
US

V. Phone/Fax

Practice location:
  • Phone: 312-738-3111
  • Fax: 312-738-5211
Mailing address:
  • Phone: 708-786-2905
  • Fax: 773-762-8500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036086899
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036049782
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036045400
License Number StateIL

VIII. Authorized Official

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