Provider Demographics
NPI:1558555060
Name:MARK J. GREENBAUM, D.P.M., P.C.
Entity Type:Organization
Organization Name:MARK J. GREENBAUM, D.P.M., P.C.
Other - Org Name:NORTHPOINTE FOOT AND ANKLE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:E
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-279-2900
Mailing Address - Street 1:PO BOX 309
Mailing Address - Street 2:
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30514-0309
Mailing Address - Country:US
Mailing Address - Phone:706-745-1500
Mailing Address - Fax:
Practice Address - Street 1:63 HIGHWAY 515 E
Practice Address - Street 2:
Practice Address - City:BLAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30512-8501
Practice Address - Country:US
Practice Address - Phone:706-745-1500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-29
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD000611213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000412068CMedicaid
GA000412068CMedicaid
GAGRP3464Medicare PIN