Basic Information
| Provider Information | |||||||||
| NPI: | 1043208911 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREENBERG | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | KEVIN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 CORPORATE BLVD | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008939698 | ||||||||
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| Practice Location | |||||||||
| Address1: | 350 FAIRVIEW HEIGHTS RD | ||||||||
| Address2: | |||||||||
| City: | SUMMERSVILLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 266511085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3048725090 | ||||||||
| FaxNumber: | 3048720636 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2005 | ||||||||
| LastUpdateDate: | 04/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 17260 | WV | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 550775750 | 01 | TAX ID | OTHER | 0053729000 | 05 | WV | MEDICAID |