Healthcare Provider Details

I. General information

NPI: 1326525320
Provider Name (Legal Business Name): ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2018
Last Update Date: 07/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2965 LONG BEACH RD
OCEANSIDE NY
11572-3255
US

IV. Provider business mailing address

2965 LONG BEACH RD
OCEANSIDE NY
11572-3255
US

V. Phone/Fax

Practice location:
  • Phone: 516-593-8953
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: ALICIA GRESHAM
Title or Position: VP OF NETWORK OPERATIONS
Credential:
Phone: 212-659-9038