Provider Demographics
NPI:1215046347
Name:MOUNT SINAI COMMUNITY FOUNDATION
Entity Type:Organization
Organization Name:MOUNT SINAI COMMUNITY FOUNDATION
Other - Org Name:SMG WEST CHICAGO PHYSICIANS ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:E
Authorized Official - Last Name:VAZQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-257-6850
Mailing Address - Street 1:1501 S CALIFORNIA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-1732
Mailing Address - Country:US
Mailing Address - Phone:708-786-2905
Mailing Address - Fax:773-762-8500
Practice Address - Street 1:610 S MAPLE AVE
Practice Address - Street 2:STE 2100
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60304-1091
Practice Address - Country:US
Practice Address - Phone:708-848-7373
Practice Address - Fax:708-848-5240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
541010Medicare PIN