Provider Demographics
NPI:1902420144
Name:ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI
Entity Type:Organization
Organization Name:ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP 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 1:150 EAST 42ND STREET
Mailing Address - Street 2:5TH FLOOR, 5.A.30.6
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10017
Mailing Address - Country:US
Mailing Address - Phone:646-605-4113
Mailing Address - Fax:
Practice Address - Street 1:485 MERRICK RD
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-5436
Practice Address - Country:US
Practice Address - Phone:516-255-9555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-03
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty