Provider Demographics
NPI:1801079371
Name:LORI L. GREENWALD, MD, PC
Entity type:Organization
Organization Name:LORI L. GREENWALD, MD, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:MICHAUD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-761-6666
Mailing Address - Street 1:1 BARNARD LN
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-2481
Mailing Address - Country:US
Mailing Address - Phone:860-761-6666
Mailing Address - Fax:860-761-2502
Practice Address - Street 1:1 BARNARD LN
Practice Address - Street 2:SUITE 201
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002-2481
Practice Address - Country:US
Practice Address - Phone:860-761-6666
Practice Address - Fax:860-761-2502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-07
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT030092174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C03461OtherMEDICARE GROUP