=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508172594
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAYNE D. NISENBAUM, DO, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2010
-----------------------------------------------------
Last Update Date | 02/18/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50 COCOANUT ROW SUITE #120
-----------------------------------------------------
City | PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33480-4025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-832-1950
-----------------------------------------------------
Fax | 561-832-1926
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 50 COCOANUT ROW SUITE #120
-----------------------------------------------------
City | PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33480-4025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-832-1950
-----------------------------------------------------
Fax | 561-832-1926
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PROVIDER
-----------------------------------------------------
Name | DR. LAYNE DAVID NISENBAUM
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 561-832-1950
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | OS0006028
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------