Provider Demographics
NPI:1720531387
Name:BRENSEKE, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BRENSEKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 MADISON AVE
Mailing Address - Street 2:5TH FL
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-1600
Mailing Address - Country:US
Mailing Address - Phone:212-545-2400
Mailing Address - Fax:646-312-0481
Practice Address - Street 1:150 ESSEX ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-2301
Practice Address - Country:US
Practice Address - Phone:212-477-1120
Practice Address - Fax:212-477-8957
Is Sole Proprietor?:No
Enumeration Date:2016-08-01
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008659133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00695941Medicaid
WI331943Medicare Oscar/Certification
NY331978Medicare Oscar/Certification
NYW6L111Medicare Oscar/Certification
WI331947Medicare Oscar/Certification
WI331954Medicare Oscar/Certification
NYG100000410Medicare Oscar/Certification
WI331009Medicare Oscar/Certification
WI331043Medicare Oscar/Certification
WI331945Medicare Oscar/Certification
WI331058Medicare Oscar/Certification
WI331952Medicare Oscar/Certification
WI331978Medicare Oscar/Certification
WI331946Medicare Oscar/Certification