Provider Demographics
NPI:1851454698
Name:MOUNT SINAI COMMUNITY FOUNDATION
Entity Type:Organization
Organization Name:MOUNT SINAI COMMUNITY FOUNDATION
Other - Org Name:SMG LAKESIDE MEDICAL CENTER
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:
Practice Address - Street 1:2218 S. MICHIGAN AVE
Practice Address - Street 2:SMG LAKESIDE MEDICAL CENTER
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-2189
Practice Address - Country:US
Practice Address - Phone:312-842-2082
Practice Address - Fax:312-842-2214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2013-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036103785207Q00000X
IL036059684207R00000X
IL036046138208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty