Healthcare Provider Details

I. General information

NPI: 1538425830
Provider Name (Legal Business Name): FACULTY PRACTICE ASSOCIATES MOUNT SINAI SCHOOL OF MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2012
Last Update Date: 04/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1184 5TH AVE 2ND FLOOR
NEW YORK NY
10029-6503
US

IV. Provider business mailing address

PO BOX 28082
NEW YORK NY
10087-8082
US

V. Phone/Fax

Practice location:
  • Phone: 212-241-0915
  • Fax:
Mailing address:
  • Phone: 212-241-8717
  • Fax: 212-241-9467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number
License Number State

VIII. Authorized Official

Name: CRYSTAL MACNEILL
Title or Position: CBO DIRECTOR, VICE PRESIDENT
Credential:
Phone: 212-731-6802