Healthcare Provider Details

I. General information

NPI: 1164623278
Provider Name (Legal Business Name): NORTH SHORE MEDICAL GROUP OF THE MOUNT SINAI SCHOOL OF MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 10/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

775 PARK AVE
HUNTINGTON NY
11743-3976
US

IV. Provider business mailing address

775 PARK AVE
HUNTINGTON NY
11743-3976
US

V. Phone/Fax

Practice location:
  • Phone: 631-659-4400
  • Fax: 631-659-4578
Mailing address:
  • Phone: 631-659-4400
  • Fax: 631-659-4578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: JANET STREET
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 631-351-3703