Provider Demographics
NPI:1407817364
Name:GREENBERG, STEVEN M (MD)
Entity Type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:M
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 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-8738
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:1880 JUDITH LANE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-3185
Practice Address - Country:US
Practice Address - Phone:208-367-6910
Practice Address - Fax:208-367-6140
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7049207Q00000X
IDM-7049207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003702400Medicaid
ID003702400Medicaid
ID11350731Medicare PIN
1135070Medicare ID - Type UnspecifiedCIGNA
G36946Medicare UPIN
1135077Medicare ID - Type UnspecifiedCIGNA
1135078Medicare ID - Type UnspecifiedCIGNA