Healthcare Provider Details

I. General information

NPI: 1154696615
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: 03/16/2012
Last Update Date: 09/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

638 COLUMBUS AVE
NEW YORK NY
10024-1406
US

IV. Provider business mailing address

1 GUSTAVE L LEVY PL # 1621
NEW YORK NY
10029-6500
US

V. Phone/Fax

Practice location:
  • Phone: 212-731-7895
  • Fax:
Mailing address:
  • Phone: 212-731-7895
  • Fax: 212-731-6788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number StateNY

VIII. Authorized Official

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