Provider Demographics
NPI:1164468120
Name:GREENSPAN, GARY A (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:A
Last Name:GREENSPAN
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 1:4200 WARRENSVILLE CENTER RD
Mailing Address - Street 2:#200
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-7051
Mailing Address - Country:US
Mailing Address - Phone:216-752-7676
Mailing Address - Fax:216-295-8041
Practice Address - Street 1:4200 WARRRENSVILLE CNTR ROAD
Practice Address - Street 2:#200
Practice Address - City:WARRENSVILLE HTS
Practice Address - State:OH
Practice Address - Zip Code:44122
Practice Address - Country:US
Practice Address - Phone:216-752-7676
Practice Address - Fax:216-295-8041
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH054667207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0668728Medicaid
110019261OtherRAILROAD
OH3059603Medicaid
OH3059603Medicaid
OH0668728Medicaid
OH0599555Medicare PIN