Healthcare Provider Details

I. General information

NPI: 1104162700
Provider Name (Legal Business Name): ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2012
Last Update Date: 12/09/2022
Certification Date: 12/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 GUSTAVE L LEVY PL
NEW YORK NY
10029-6504
US

IV. Provider business mailing address

150 E 42ND ST FL 2
NEW YORK NY
10017-5612
US

V. Phone/Fax

Practice location:
  • Phone: 212-241-6500
  • Fax:
Mailing address:
  • Phone: 646-605-8119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name: EDWARD A PETERSON
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 646-605-8145