Healthcare Provider Details

I. General information

NPI: 1659545986
Provider Name (Legal Business Name): MOUNT SINAI MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2008
Last Update Date: 04/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5030 N RIDGEWAY AVE UNIT 2
CHICAGO IL
60625-6022
US

IV. Provider business mailing address

CALIFORNIA AVE AT 15TH ST. F44
CHICAGO IL
60608
US

V. Phone/Fax

Practice location:
  • Phone: 773-257-6183
  • Fax:
Mailing address:
  • Phone: 773-257-6183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC2000X
TaxonomyChildren's Hospital
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. MELISSA PENETRANTE MANAIG
Title or Position: HOUSE STAFF RESIDENT PL-3
Credential: M.D.
Phone: 773-257-1885