Provider Demographics
NPI:1417343591
Name:MOUNT SINAI COMMUNITY FOUNDATION
Entity Type:Organization
Organization Name:MOUNT SINAI COMMUNITY FOUNDATION
Other - Org Name:SMG AT SCI FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
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:NR6-119
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-1732
Mailing Address - Country:US
Mailing Address - Phone:773-257-2905
Mailing Address - Fax:773-257-1788
Practice Address - Street 1:2653 W OGDEN AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1647
Practice Address - Country:US
Practice Address - Phone:773-257-6840
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOUNT SINAI COMMUNITY FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-04-15
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty