Provider Demographics
NPI:1477926384
Name:ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI
Entity Type:Organization
Organization Name:ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI
Other - Org Name:MOUNT SINAI DOCTORS CCSI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF NETWORK OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRESHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-659-9038
Mailing Address - Street 1:11 RALPH PL
Mailing Address - Street 2:SUITE 109
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-4401
Mailing Address - Country:US
Mailing Address - Phone:718-981-3674
Mailing Address - Fax:
Practice Address - Street 1:11 RALPH PL
Practice Address - Street 2:SUITE 109
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-4401
Practice Address - Country:US
Practice Address - Phone:718-981-3674
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOUNT SINAI HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-11-02
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty