=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033496591
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLEARLY MADISON, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/12/2011
-----------------------------------------------------
Last Update Date | 03/05/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 161 MADISON AVE SUITE 5SE
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10016-5421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-448-0101
-----------------------------------------------------
Fax | 212-448-0116
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 161 MADISON AVE SUITE 5SE
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10016-5421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-448-0101
-----------------------------------------------------
Fax | 212-448-0116
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JOSHUA ABBA YOUNG
-----------------------------------------------------
Credential | M.D,
-----------------------------------------------------
Telephone | 212-448-0101
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 187808-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------