Provider Demographics
NPI:1164412136
Name:GREENBERG, JAMES J (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:J
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:N2950 STATE ROAD 67
Mailing Address - Street 2:
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-2655
Mailing Address - Country:US
Mailing Address - Phone:262-245-0535
Mailing Address - Fax:
Practice Address - Street 1:N2950 STATE ROAD 67
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-2655
Practice Address - Country:US
Practice Address - Phone:262-245-0535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-087181208600000X
WI53948208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036087181Medicaid
WIGREENJAMOtherMERCYCARE INSURANCE
01619787OtherBCBSIL GROUP NUMBER
IL020040377Medicare PIN
IL517410Medicare PIN
ILG28539Medicare UPIN
IL036087181Medicaid
WI541760708Medicare PIN
WIGREENJAMOtherMERCYCARE INSURANCE
IL214660034Medicare PIN
ILCI2940Medicare PIN
ILL78449Medicare PIN