=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912276643
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARC A. BRENNER, D.P.M., PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2011
-----------------------------------------------------
Last Update Date | 01/03/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2001 MARCUS AVENUE
-----------------------------------------------------
City | LAKE SUCCESS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-355-2277
-----------------------------------------------------
Fax | 516-626-9243
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 83 WHEATLEY RD
-----------------------------------------------------
City | OLD WESTBURY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11568-1210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-355-2277
-----------------------------------------------------
Fax | 516-626-9243
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING SPECIALIST
-----------------------------------------------------
Name | SHARESE WELCH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 718-573-1123
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | N002371-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------