Provider Demographics
NPI:1770665101
Name:GREENBERG, MICHAEL G (PA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
Last Name:GREENBERG
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10500 QUIVIRA RD
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66215-2306
Mailing Address - Country:US
Mailing Address - Phone:913-541-5340
Mailing Address - Fax:
Practice Address - Street 1:10500 QUIVIRA RD
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66215-2306
Practice Address - Country:US
Practice Address - Phone:913-541-5340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005032882363AM0700X
KS1501063363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOQ61582Medicare UPIN
KSR86E334BMedicare ID - Type UnspecifiedMEDICARE
MOR86E334Medicare ID - Type UnspecifiedMEDICARE
MOR86E334AMedicare ID - Type UnspecifiedMEDICARE