Provider Demographics
NPI:1831175819
Name:GREENWALD, NANCY (MD)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:GREENWALD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 ROBBINS RD
Mailing Address - Street 2:#300
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-4565
Mailing Address - Country:US
Mailing Address - Phone:208-489-4016
Mailing Address - Fax:208-489-5188
Practice Address - Street 1:600 ROBBINS RD
Practice Address - Street 2:#300
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4565
Practice Address - Country:US
Practice Address - Phone:208-489-4016
Practice Address - Fax:208-489-5188
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7342208100000X
ORMD21541208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDM7342OtherSTATE LICENSE
ID1831175819Medicaid