Provider Demographics
NPI:1932187390
Name:GREENBERG, LISE M (MD)
Entity Type:Individual
Prefix:
First Name:LISE
Middle Name:M
Last Name:GREENBERG
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 1:9910 FRANKLIN SQUARE DR # 2110
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21236-4902
Mailing Address - Country:US
Mailing Address - Phone:410-933-5412
Mailing Address - Fax:
Practice Address - Street 1:103 BATA BLVD STE A
Practice Address - Street 2:
Practice Address - City:BELCAMP
Practice Address - State:MD
Practice Address - Zip Code:21017
Practice Address - Country:US
Practice Address - Phone:410-575-6611
Practice Address - Fax:410-367-2141
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0057137207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
522338017OtherMHIP
522338017OtherPHCS
MDKJ15GB/P18428OtherCAREFIRST MPOS-GBMC
522338017OtherCOVENTRY
522338017OtherHELIX
522338017OtherUHC
MD698201800Medicaid
2683650OtherAETNA HMO
K582OtherMPOS
7132271OtherAETNA PPO
813176OtherMAMSI
MDS138-0163OtherCAREFIRST REGIONAL GBMC
15185OtherHEALTHNET
522338017OtherCIGNA
MDKJ15GB/611506-03OtherCAREFIRST MARYLAND
W647001UOtherBLUE CHOICE
K582OtherMPOS
MD712L/148650YBPGMedicare PIN
522338017OtherCOVENTRY
H50563Medicare UPIN