Provider Demographics
NPI:1437109196
Name:MARK A. GREENBERGER, M.D., S.C.
Entity Type:Organization
Organization Name:MARK A. GREENBERGER, M.D., S.C.
Other - Org Name:MAURICE B. PICKARD, M.D. AND MARK A. GREENBERGER, M.D., S.C.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:GREENBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-433-0404
Mailing Address - Street 1:480 ELM PL
Mailing Address - Street 2:SUITE 203
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-2538
Mailing Address - Country:US
Mailing Address - Phone:847-433-0404
Mailing Address - Fax:847-433-1389
Practice Address - Street 1:480 ELM PL
Practice Address - Street 2:SUITE 203
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-2538
Practice Address - Country:US
Practice Address - Phone:847-433-0404
Practice Address - Fax:847-433-1389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042618739207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
4900615OtherBLUECROSS/BLUESHIELD GOUP
4900615OtherBLUECROSS/BLUESHIELD GOUP