Healthcare Provider Details

I. General information

NPI: 1598199432
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: 08/28/2013
Last Update Date: 08/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 SOUTHERN BLVD
NESCONSET NY
11767-1089
US

IV. Provider business mailing address

61 SOUTHERN BLVD
NESCONSET NY
11767-1089
US

V. Phone/Fax

Practice location:
  • Phone: 631-659-1800
  • Fax:
Mailing address:
  • Phone: 631-659-1800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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