Healthcare Provider Details

I. General information

NPI: 1215046347
Provider Name (Legal Business Name): MOUNT SINAI COMMUNITY FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 05/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 S MAPLE AVE STE 2100
OAK PARK IL
60304-1091
US

IV. Provider business mailing address

1501 S CALIFORNIA AVE
CHICAGO IL
60608-1732
US

V. Phone/Fax

Practice location:
  • Phone: 708-848-7373
  • Fax: 708-848-5240
Mailing address:
  • Phone: 708-786-2905
  • Fax: 773-762-8500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

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