1164468120 NPI number — GARY A GREENSPAN MD

Table of content: GARY A GREENSPAN MD (NPI 1164468120)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164468120 NPI number — GARY A GREENSPAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREENSPAN
Provider First Name:
GARY
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1164468120
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/13/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 660
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MENTOR
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44061-0660
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-854-0217
Provider Business Mailing Address Fax Number:
440-516-3783

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4200 WARRRENSVILLE CNTR ROAD
Provider Second Line Business Practice Location Address:
#200
Provider Business Practice Location Address City Name:
WARRENSVILLE HTS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44122
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-752-7676
Provider Business Practice Location Address Fax Number:
216-295-8041
Provider Enumeration Date:
06/20/2006

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: 207R00000X , with the licence number:  054667 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0668728 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3059603 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110019261 . This is a "RAILROAD" identifier . This identifiers is of the category "OTHER".




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