Provider Demographics
NPI:1891329488
Name:MT SINAI PEDIATRIC CENTER FFS
Entity Type:Organization
Organization Name:MT SINAI PEDIATRIC CENTER FFS
Other - Org Name:MT SINAI PEDIATRIC CENTER FFS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF MANAGED CARE OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDRLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-864-4649
Mailing Address - Street 1:1900 W POLK ST RM 220C
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3723
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2653 W OGDEN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1647
Practice Address - Country:US
Practice Address - Phone:773-522-2010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COOK COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-02-24
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty