Healthcare Provider Details

I. General information

NPI: 1033482518
Provider Name (Legal Business Name): ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2012
Last Update Date: 06/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 MADISON AVE
NEW YORK NY
10029-6514
US

IV. Provider business mailing address

P.O. BOX 28082
NEW YORK NY
10087-8082
US

V. Phone/Fax

Practice location:
  • Phone: 212-987-3100
  • Fax: 212-731-5220
Mailing address:
  • Phone: 212-731-7696
  • Fax: 212-348-6158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State

VIII. Authorized Official

Name: CRYSTAL MACNEILL
Title or Position: VICE PRESIDENT,CBO DIRECTOR
Credential:
Phone: 646-605-8112