SIGN UP To become an IPA member, please complete and submit the form below. If you are already a member or employed by the Icahn School of Medicine, you do NOT need to submit the form. Instead, please inquire about membership within your department. 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 NAMESPECIALTY Do you, or your group, belong to another Independent Practice Association (IPA)?* YES NO (If yes, please provide name of IPA). Office ContactNAME JOB TITLE EMAIL PHONECAPTCHA Δ