Healthcare Provider Details

I. General information

NPI: 1912499401
Provider Name (Legal Business Name): ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2018
Last Update Date: 06/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2209 MERRICK RD STE 101
MERRICK NY
11566
US

IV. Provider business mailing address

1 HEALTHY WAY
OCEANSIDE NY
11572-1551
US

V. Phone/Fax

Practice location:
  • Phone: 516-546-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WX0200X
TaxonomyOncology Registered Nurse
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State

VIII. Authorized Official

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