=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952703456
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARK J. SCHILLER, M.D., PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/16/2014
-----------------------------------------------------
Last Update Date | 09/16/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 150 NELLEN AVE STE. 100
-----------------------------------------------------
City | CORTE MADERA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94925-1104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-945-9870
-----------------------------------------------------
Fax | 415-945-9325
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 150 NELLEN AVE STE. 100
-----------------------------------------------------
City | CORTE MADERA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94925-1104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-945-9870
-----------------------------------------------------
Fax | 415-945-9325
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. MARK J. SCHILLER
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 415-945-9870
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | G76519
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------