Provider Demographics
NPI:1619338464
Name:ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI
Entity Type:Organization
Organization Name:ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI
Other - Org Name:ENT DENTISTRY DEPARTMENT OF MOUNT SINAI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT, CBO DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:MACNEILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-605-8112
Mailing Address - Street 1:150 E 42ND ST
Mailing Address - Street 2:10TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10017-5612
Mailing Address - Country:US
Mailing Address - Phone:646-605-8119
Mailing Address - Fax:646-605-3031
Practice Address - Street 1:1 GUSTAVE L LEVY PL
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6504
Practice Address - Country:US
Practice Address - Phone:212-241-9410
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-08
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Multi-Specialty