Healthcare Provider Details

I. General information

NPI: 1508124553
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: 04/27/2012
Last Update Date: 04/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 E 102ND ST SUITE 215
NEW YORK NY
10029-5611
US

IV. Provider business mailing address

PO BOX 28082
NEW YORK NY
10087-8082
US

V. Phone/Fax

Practice location:
  • Phone: 212-241-6336
  • Fax:
Mailing address:
  • Phone: 212-241-6336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CRYSTAL MACNEILL
Title or Position: VICE PRESIDENT, CBO DIRECTOR
Credential:
Phone: 212-731-6870