Provider Demographics
NPI:1558309963
Name:BRUCE R. GREENBAUM DPM PC
Entity Type:Organization
Organization Name:BRUCE R. GREENBAUM DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:ROY
Authorized Official - Last Name:GREENBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:719-265-2600
Mailing Address - Street 1:3000 OCEAN PKWY
Mailing Address - Street 2:SUITE 2G
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-8367
Mailing Address - Country:US
Mailing Address - Phone:718-265-2600
Mailing Address - Fax:718-265-0345
Practice Address - Street 1:3000 OCEAN PKWY
Practice Address - Street 2:SUITE 2G
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-8367
Practice Address - Country:US
Practice Address - Phone:718-265-2600
Practice Address - Fax:718-265-0345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004557213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WP8021OtherMEDICARE GRP
NY01190069Medicaid
NY01190069Medicaid
NY4582460001Medicare NSC