1538197173 NPI number — JAYSON SCOTT GREENBERG M.D.

Table of content: JAYSON SCOTT GREENBERG M.D. (NPI 1538197173)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538197173 NPI number — JAYSON SCOTT GREENBERG M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREENBERG
Provider First Name:
JAYSON
Provider Middle Name:
SCOTT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538197173
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/13/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3621 S STATE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANN ARBOR
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48108-1633
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-647-5299
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7500 CHALLIS RD
Provider Second Line Business Practice Location Address:
1ST FLOOR
Provider Business Practice Location Address City Name:
BRIGHTON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48116-9416
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-263-4000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/30/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Y00000X , with the licence number:  4301078781 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 10-20013 . This is a "PHYSICIAN HEALTH PLAN UHC" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4405491-10 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0403811832 . This is a "BLUE CROSS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".