Provider Demographics
NPI:1134164841
Name:MOUNT SINAI COMMUNITY FOUNDATION
Entity type:Organization
Organization Name:MOUNT SINAI COMMUNITY FOUNDATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
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
Mailing Address - Country:US
Mailing Address - Phone:708-786-2905
Mailing Address - Fax:847-635-2076
Practice Address - Street 1:1400 E. GOLF RD
Practice Address - Street 2:SUITE 118
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016
Practice Address - Country:US
Practice Address - Phone:847-635-2001
Practice Address - Fax:847-635-2076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036112813207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL760829636-60016-02Medicaid
IL760829636-60016-02Medicaid
IL213797Medicare PIN