NPIMap

Organization Active NPI

Icahn School of Medicine at Mount Sinai

Doing business as Mt Sinai Doctors Staten Island Medicine

  • Internal Medicine Physician
  • Staten Island, NY
National Provider Identifier
1861900888
Registry record updated Jan 11, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
Legal business name
ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI
Doing business as
Mt Sinai Doctors Staten Island Medicine
Practice address
283 Bard Ave
Staten Island, NY 10310-1664
Phone
(718) 816-8068
Fax
(718) 448-6299
NPI assigned
Jan 11, 2018
Last updated
Jan 11, 2018By the provider in NPPES
Organization subpart
Yes
Parent organization
MOUNT SINAI HOSPITALAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jan 11, 2018

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Alicia Gresham
Title
VP of Network Operations
Phone
(212) 659-9038

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207R00000X Primary

Addresses

Primary practice location

283 Bard Ave
Staten Island, NY 10310-1664

Mailing address

283 Bard Ave
Staten Island, NY 10310-1664
Phone (718) 816-8068

Other names 1

  • MT SINAI DOCTORS STATEN ISLAND MEDICINE Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NY

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20180928002222 NY Part B Supplier - Clinic/Group Practice 4880945955 Receives reassigned benefits from 59 practitioners
1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Staten Island, NY

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
33D2234209Mount Siani Doctors Staten Island Medicine283 Bard Ave, Staten Island, NY 10310Certificate of waiverMar 26, 2027

National Provider Directory

National Provider Directory
Tax ID family
Icahn School of Medicine at Mount Sinai2 organizations share this tax ID, including this one
Part of
Mt Sinai Hosp Clinical

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Locations

11 Ralph Pl
Ste 201
Staten Island, NY 10304
Phone (718) 556-6565

283 Bard Ave
Staten Island, NY 10310
Phone (718) 816-6068

754 Manor Rd
Staten Island, NY 10314
Phone (718) 273-5522

Practitioners & affiliated clinicians

Practitioners 37

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 37

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1515628800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1515628800000",
    "number": "1861900888",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "283 BARD AVE",
            "city": "STATEN ISLAND",
            "state": "NY",
            "postal_code": "103101664",
            "telephone_number": "718-816-8068",
            "fax_number": "718-448-6299"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "283 BARD AVE",
            "city": "STATEN ISLAND",
            "state": "NY",
            "postal_code": "103101664",
            "telephone_number": "718-816-8068",
            "fax_number": "718-448-6299"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MOUNT SINAI HOSPITAL",
        "enumeration_date": "2018-01-11",
        "last_updated": "2018-01-11",
        "status": "A",
        "authorized_official_last_name": "GRESHAM",
        "authorized_official_first_name": "ALICIA",
        "authorized_official_title_or_position": "VP OF NETWORK OPERATIONS",
        "authorized_official_telephone_number": "212-659-9038"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "MT SINAI DOCTORS STATEN ISLAND MEDICINE",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Staten Island, NY

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 11, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.