=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902162308
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FACULTY PRACTICE ASSOCIATES MOUNT SINAI SCHOOL OF MEDICINE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2012
-----------------------------------------------------
Last Update Date | 04/10/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5 E 98TH ST FL 9
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10029-6501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-241-6980
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 28082
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10087-8082
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-241-6980
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CBO DIRECTOR, VICE PRESIDENT
-----------------------------------------------------
Name | CRYSTAL MACNEILL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 212-731-6802
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------