Provider Demographics
NPI:1093949729
Name:MOUNT SINAI FAMILY PRACTICE RESIDENCY PROGRAM OF CHICAGO
Entity Type:Organization
Organization Name:MOUNT SINAI FAMILY PRACTICE RESIDENCY PROGRAM OF CHICAGO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RESIDENT/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:R
Authorized Official - Last Name:CISNEROS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-257-6097
Mailing Address - Street 1:1644 S CORA ST
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60018-2210
Mailing Address - Country:US
Mailing Address - Phone:312-860-1058
Mailing Address - Fax:
Practice Address - Street 1:1500 S CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1729
Practice Address - Country:US
Practice Address - Phone:773-257-6097
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-09
Last Update Date:2009-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036117932282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital