Healthcare Provider Details

I. General information

NPI: 1710408596
Provider Name (Legal Business Name): ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2017
Last Update Date: 08/06/2020
Certification Date: 08/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 RIVER RD FL 2
EDGEWATER NJ
07020-1016
US

IV. Provider business mailing address

103 RIVER RD FL 2
EDGEWATER NJ
07020-1016
US

V. Phone/Fax

Practice location:
  • Phone: 201-941-8100
  • Fax: 201-941-2899
Mailing address:
  • Phone: 201-941-8100
  • Fax: 201-941-2899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: ALICIA GRESHAM
Title or Position: VP OF NETWORK OPERATIONS
Credential:
Phone: 212-659-9038