Sign Up PHYSICIAN NAME SPECIALTY NPI NUMBER Do you have Hospital Admitting Privileges at any of the following Mount Sinai System Campuses? (Check all that apply). MEMBERS Mount Sinai Hospital Mount Sinai Beth Israel Mount Sinai Beth Israel Brooklyn Mount Sinai Queens Mount Sinai Roosevelt Mount Sinai St. Luke’s New York Eye and Ear Infirmary of Mount Sinai If you are in a group practice and bill under the same TIN, all associated practice physicians must join The Mount Sinai IPA. No exceptions will be made. All physicians must have visiting/attending privileges in writing at Mount Sinai System Campuses. Please contact the MSH Medical Staff Office to inquire about physician privileges (212-241-6500). List all associated physicians in the available space below. NAME OF PRACTICE PHYSICIAN NAME SPECIALTY Do you, or your group, belong to another Independent Practice Association (IPA)?* YES NO (If yes, please provide name of IPA). Office Contact NAME JOB TITLE EMAIL PHONE CAPTCHA
PHYSICIAN NAME SPECIALTY NPI NUMBER Do you have Hospital Admitting Privileges at any of the following Mount Sinai System Campuses? (Check all that apply). MEMBERS Mount Sinai Hospital Mount Sinai Beth Israel Mount Sinai Beth Israel Brooklyn Mount Sinai Queens Mount Sinai Roosevelt Mount Sinai St. Luke’s New York Eye and Ear Infirmary of Mount Sinai If you are in a group practice and bill under the same TIN, all associated practice physicians must join The Mount Sinai IPA. No exceptions will be made. All physicians must have visiting/attending privileges in writing at Mount Sinai System Campuses. Please contact the MSH Medical Staff Office to inquire about physician privileges (212-241-6500). List all associated physicians in the available space below. NAME OF PRACTICE PHYSICIAN NAME SPECIALTY Do you, or your group, belong to another Independent Practice Association (IPA)?* YES NO (If yes, please provide name of IPA). Office Contact NAME JOB TITLE EMAIL PHONE CAPTCHA