Provider Demographics
NPI:1043208911
Name:GREENBERG, BRUCE KEVIN (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:KEVIN
Last Name:GREENBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 CORPORATE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:350 FAIRVIEW HEIGHTS RD
Practice Address - Street 2:
Practice Address - City:SUMMERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26651-1085
Practice Address - Country:US
Practice Address - Phone:304-872-5090
Practice Address - Fax:304-872-0636
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV17260207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
550775750OtherTAX ID
WV0053729000Medicaid
WV0740014Medicare ID - Type Unspecified
550775750OtherTAX ID