Provider Demographics
NPI:1700850807
Name:GREENWALD, MARC A (MD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:A
Last Name:GREENWALD
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 1:680 CENTRE STREET
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302
Mailing Address - Country:US
Mailing Address - Phone:508-941-7202
Mailing Address - Fax:508-941-6388
Practice Address - Street 1:680 CENTRE STREET
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302
Practice Address - Country:US
Practice Address - Phone:508-941-7202
Practice Address - Fax:508-941-6388
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA220491207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0406618OtherEVERCARE
4094854OtherAETNA US HEALTHCARE
4599158OtherCIGNA HEALTH PLAN
AA10928OtherHARVARD PILGRIM
J27427OtherBLUE SHIELD INDEMNITY
67982OtherFALLON COMM HEALTH PLAN
042472266OtherPRIVATE HEALTHCARE SYSTEM
2225093OtherFIRST HEALTH
042472266OtherTHREE RIVERS
467892OtherTUFTS HEALTH PLAN
042472266OtherONE HEALTH PLAN
J27427OtherBLUE SHIELD HMO BLUE
042472266OtherUNITED HEALTHCARE
MA2037114Medicaid
784025OtherMVP HEALTH CARE
J27427OtherBLUE CARE ELECT
J27427OtherBLUE SHIELD HMO BLUE
2225093OtherFIRST HEALTH