Healthcare Provider Details

I. General information

NPI: 1578817540
Provider Name (Legal Business Name): ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2012
Last Update Date: 02/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7901 BROADWAY
ELMHURST NY
11373-1329
US

IV. Provider business mailing address

7901 BROADWAY
ELMHURST NY
11373-1329
US

V. Phone/Fax

Practice location:
  • Phone: 718-334-1591
  • Fax: 718-334-4815
Mailing address:
  • Phone: 718-334-1591
  • Fax: 718-334-4815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MARTIN J FINE
Title or Position: DIRECTOR, FACULTY PRACTICE GROUP
Credential: MD
Phone: 718-334-1591