Provider Demographics
NPI:1609142041
Name:GREENBERG, JEREMY ADAM (MD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:ADAM
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 1:979 E 3RD ST STE C735
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37403-3310
Mailing Address - Country:US
Mailing Address - Phone:423-778-9101
Mailing Address - Fax:423-778-9190
Practice Address - Street 1:979 E 3RD ST STE C735
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403
Practice Address - Country:US
Practice Address - Phone:423-778-9101
Practice Address - Fax:423-778-9190
Is Sole Proprietor?:No
Enumeration Date:2012-03-29
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN51072207RC0200X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN51072OtherTENNESSEE MEDICAL LICENSE