Provider Demographics
NPI:1750678934
Name:MOUNT SINAI HOSPITAL MEDICAL CENTER
Entity Type:Organization
Organization Name:MOUNT SINAI HOSPITAL MEDICAL CENTER
Other - Org Name:PIONEER HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT/COO
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:C
Authorized Official - Last Name:TEITELBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-257-5332
Mailing Address - Street 1:812 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4140
Mailing Address - Country:US
Mailing Address - Phone:312-666-6897
Mailing Address - Fax:
Practice Address - Street 1:812 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4140
Practice Address - Country:US
Practice Address - Phone:312-666-6897
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-07
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0001644261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1932496114Medicaid
IL1639470867Medicaid