Healthcare Provider Details

I. General information

NPI: 1396212536
Provider Name (Legal Business Name): MOUNT SINAI SCHOOL OF MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2018
Last Update Date: 01/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HEALTHY WAY
OCEANSIDE NY
11572-1551
US

IV. Provider business mailing address

119 N PARK AVE STE 101
ROCKVILLE CENTRE NY
11570-4113
US

V. Phone/Fax

Practice location:
  • Phone: 516-632-3921
  • Fax:
Mailing address:
  • Phone: 516-255-9555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number
License Number State

VIII. Authorized Official

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