Healthcare Provider Details

I. General information

NPI: 1063800084
Provider Name (Legal Business Name): FACULTY PRACTICE ASSOCIATES - MT. SINAI SCHOOL OF MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2014
Last Update Date: 12/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1428 MADISON AVE, 1ST FLOOR
NEW YORK NY
10029-6574
US

IV. Provider business mailing address

1 GUSTAVE L. LEVY PLACE, BOX 1497
NEW YORK NY
10029-6574
US

V. Phone/Fax

Practice location:
  • Phone: 212-241-6947
  • Fax: 212-860-3316
Mailing address:
  • Phone: 212-241-6947
  • Fax: 212-860-3316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number200748
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number200748
License Number StateNY

VIII. Authorized Official

Name: MR. SEAN CLARKE
Title or Position: CLIN PRACTICE MGR
Credential:
Phone: 212-241-3055