Healthcare Provider Details

I. General information

NPI: 1902420144
Provider Name (Legal Business Name): ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2020
Last Update Date: 06/03/2020
Certification Date: 06/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

485 MERRICK RD
ROCKVILLE CENTRE NY
11570-5436
US

IV. Provider business mailing address

150 EAST 42ND STREET 5TH FLOOR, 5.A.30.6
NEW YORK NY
10017
US

V. Phone/Fax

Practice location:
  • Phone: 516-255-9555
  • Fax:
Mailing address:
  • Phone: 646-605-4113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number
License Number State

VIII. Authorized Official

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