Provider Demographics
NPI:1497860720
Name:GREENBERGER, MARK D (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:GREENBERGER
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 1:6029 WALNUT GROVE RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-2112
Mailing Address - Country:US
Mailing Address - Phone:901-767-8158
Mailing Address - Fax:901-767-1555
Practice Address - Street 1:6029 WALNUT GROVE RD
Practice Address - Street 2:SUITE 300
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2112
Practice Address - Country:US
Practice Address - Phone:901-767-8158
Practice Address - Fax:901-767-1555
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16815208800000X
TN28010208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3809034Medicaid
7120129OtherAETNA
MS0123339Medicaid
AR131430001Medicaid
3601198OtherCIGNA
P00399926OtherRR MEDICARE
MS0123339Medicaid
TNG46785Medicare UPIN
MS0123339Medicaid
3601198OtherCIGNA