Provider Demographics
NPI:1912499401
Name:ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI
Entity Type:Organization
Organization Name:ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI
Other - Org Name:MOUNT SINAI DOCTORS SOUTH NASSAU - HEMATOLOGY / ONCOLOGY
Other - Org Type:Other Name
Authorized Official - Title/Position:VP OF 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 1:1 HEALTHY WAY
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-1551
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2209 MERRICK RD STE 101
Practice Address - Street 2:
Practice Address - City:MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566
Practice Address - Country:US
Practice Address - Phone:516-546-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-31
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
No163WM0705XNursing Service ProvidersRegistered NurseMedical-SurgicalGroup - Single Specialty
No163WX0200XNursing Service ProvidersRegistered NurseOncologyGroup - Single Specialty
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty