Healthcare Provider Details

I. General information

NPI: 1679083984
Provider Name (Legal Business Name): ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2017
Last Update Date: 10/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 E 42ND ST FL 10
NEW YORK NY
10017-5626
US

IV. Provider business mailing address

150 E 42ND ST FL 10
NEW YORK NY
10017-5626
US

V. Phone/Fax

Practice location:
  • Phone: 646-605-8119
  • Fax:
Mailing address:
  • Phone: 646-605-8119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. EDWARD PETERSON
Title or Position: SENIOR DIRECTOR, CBO
Credential:
Phone: 646-605-8145