Provider Demographics
NPI:1003121013
Name:NORTH SHORE MEDICAL GROUP OF MT SINAI SCHOOL OF MEDICINE
Entity Type:Organization
Organization Name:NORTH SHORE MEDICAL GROUP OF MT SINAI SCHOOL OF MEDICINE
Other - Org Name:NORTH SHORE MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:
Authorized Official - Last Name:STREET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-351-3703
Mailing Address - Street 1:201 PORTION RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:LAKE RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-4172
Mailing Address - Country:US
Mailing Address - Phone:631-585-5959
Mailing Address - Fax:
Practice Address - Street 1:201 PORTION RD
Practice Address - Street 2:SUITE C
Practice Address - City:LAKE RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-4172
Practice Address - Country:US
Practice Address - Phone:631-585-5959
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-13
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty