Provider Demographics
NPI:1265499594
Name:GREENSPAN, ROMAN (MD)
Entity Type:Individual
Prefix:
First Name:ROMAN
Middle Name:
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 1:900 WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:WEST POINT
Mailing Address - State:NY
Mailing Address - Zip Code:10996-1109
Mailing Address - Country:US
Mailing Address - Phone:845-938-4114
Mailing Address - Fax:845-938-1120
Practice Address - Street 1:900 WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:WEST POINT
Practice Address - State:NY
Practice Address - Zip Code:10996-1109
Practice Address - Country:US
Practice Address - Phone:845-938-4114
Practice Address - Fax:845-938-1120
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC24905207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCRHC107Medicaid
SC249056Medicaid
SC249056Medicaid
SCAA03916978Medicare ID - Type Unspecified
SCI05120Medicare UPIN
SC428939Medicare UPIN