Provider Demographics
NPI:1912458068
Name:GREENWICH BAY MEDICAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:GREENWICH BAY MEDICAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-889-3669
Mailing Address - Street 1:4300 POST ROAD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02818
Mailing Address - Country:US
Mailing Address - Phone:401-889-3669
Mailing Address - Fax:
Practice Address - Street 1:4300 POST ROAD
Practice Address - Street 2:SUITE 1
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02818
Practice Address - Country:US
Practice Address - Phone:401-889-3669
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-24
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI=========OtherTAX ID NUMBER