Provider Demographics
NPI:1215008339
Name:GREENBERG, KEITH H (DO)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:H
Last Name:GREENBERG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:261 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-3938
Mailing Address - Country:US
Mailing Address - Phone:516-432-0768
Mailing Address - Fax:
Practice Address - Street 1:200 W 54TH ST
Practice Address - Street 2:SUITE 1C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-5504
Practice Address - Country:US
Practice Address - Phone:212-664-0030
Practice Address - Fax:212-664-8506
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-11
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY222711207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYH51915Medicare UPIN