1215975099 NPI number — STEPHEN R GREENBERG MD

Table of content: STEPHEN R GREENBERG MD (NPI 1215975099)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215975099 NPI number — STEPHEN R GREENBERG MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREENBERG
Provider First Name:
STEPHEN
Provider Middle Name:
R
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:
1215975099
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/25/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
63 EVERETT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHBRIDGE
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01550-2619
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-561-0896
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10 WOODLAND RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT HELENA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94574-9554
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-963-3611
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/03/2006

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: 2084P0800X , with the licence number:  39563 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X , with the licence number: G136688 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2084P0800X , with the licence number: 48510 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2559780 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000361467 . This is a "BLUE CROSS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 3810002249 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 64100092 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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