=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194332932
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 28TH AND MADISON LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2020
-----------------------------------------------------
Last Update Date | 09/25/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 76 MADISON AVE
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10016-8724
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-770-2091
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 212 W 18TH ST APT 9F
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10011-4554
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-307-3822
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. COURTNEY AUDRA SCHIEFELBEIIN
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 646-770-2091
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------