Provider Demographics
NPI:1912018565
Name:GREENBAUM, MONICA MARROQUIN (MD)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:MARROQUIN
Last Name:GREENBAUM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MONICA
Other - Middle Name:
Other - Last Name:MARROQUIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1 INDEPENDENCE PT
Mailing Address - Street 2:SUITE 212
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4545
Mailing Address - Country:US
Mailing Address - Phone:864-797-6044
Mailing Address - Fax:864-797-6198
Practice Address - Street 1:20 MEDICAL RIDGE DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4267
Practice Address - Country:US
Practice Address - Phone:864-220-7270
Practice Address - Fax:864-220-7290
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD44444208000000X
SC36276208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1515175Medicaid
TN1515175Medicaid
TN103I375399Medicare PIN