Healthcare Provider Details

I. General information

NPI: 1740773936
Provider Name (Legal Business Name): ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2018
Last Update Date: 01/17/2020
Certification Date: 01/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 RICHMOND RD
STATEN ISLAND NY
10306-2552
US

IV. Provider business mailing address

1910 RICHMOND RD
STATEN ISLAND NY
10306-2552
US

V. Phone/Fax

Practice location:
  • Phone: 718-987-9777
  • Fax:
Mailing address:
  • Phone: 718-987-1430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State

VIII. Authorized Official

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