Healthcare Provider Details

I. General information

NPI: 1114476371
Provider Name (Legal Business Name): ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2016
Last Update Date: 09/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 E 14TH ST 6 FL NORTH
NEW YORK NY
10003-4201
US

IV. Provider business mailing address

310 E 14TH ST 6TH FLOOR
NEW YORK NY
10003-4201
US

V. Phone/Fax

Practice location:
  • Phone: 212-979-4200
  • Fax:
Mailing address:
  • Phone: 212-353-5776
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207YX0901X
TaxonomyOtology & Neurotology Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. CRYSTAL MACNEILL
Title or Position: VICE PRESIDENT, CBO DIRECTOR
Credential:
Phone: 646-605-8112