Provider Demographics
NPI:1184767162
Name:GREENRIDGE HEALTH PARTNERS
Entity type:Organization
Organization Name:GREENRIDGE HEALTH PARTNERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:LLOYD
Authorized Official - Last Name:TRADER
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:410-821-9620
Mailing Address - Street 1:1300 YORK ROAD
Mailing Address - Street 2:BLDG A SUITE 100
Mailing Address - City:TIMONIUM
Mailing Address - State:MD
Mailing Address - Zip Code:21093-6016
Mailing Address - Country:US
Mailing Address - Phone:410-821-9620
Mailing Address - Fax:410-821-9624
Practice Address - Street 1:1300 YORK RD
Practice Address - Street 2:BLDG A SUITE 100
Practice Address - City:TIMONIUM
Practice Address - State:MD
Practice Address - Zip Code:21093-6016
Practice Address - Country:US
Practice Address - Phone:410-821-9620
Practice Address - Fax:410-821-9624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD248P524GMedicare ID - Type UnspecifiedPRIMARY CARE