Provider Demographics
NPI:1265479976
Name:GREENBERG, MICHAEL L (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:GREENBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MIKHAIL
Other - Middle Name:L
Other - Last Name:GRINBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:11115 QUEENS BLVD
Mailing Address - Street 2:FL 2
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-7479
Mailing Address - Country:US
Mailing Address - Phone:718-544-6448
Mailing Address - Fax:718-544-7719
Practice Address - Street 1:11115 QUEENS BLVD
Practice Address - Street 2:FL 2
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-7479
Practice Address - Country:US
Practice Address - Phone:718-544-6448
Practice Address - Fax:718-544-7719
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY214334207R00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01950889Medicaid