Basic Information
| Provider Information | |||||||||
| NPI: | 1225007206 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREENWALD | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | HOWARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5555 GLENWOOD HILLS PKWY SE STE 2 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495122091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169402662 | ||||||||
| FaxNumber: | 6169401965 | ||||||||
| Practice Location | |||||||||
| Address1: | 2060 EAST PARIS AVE SE STE 200 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495466113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169402662 | ||||||||
| FaxNumber: | 6162851006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 05/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | 4301092434 | MI | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 208VP0014X | 01058148A | IN | N | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 208VP0014X | 4301092434 | MI | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 9107623 | 01 | IN | PHCS PID NUMBER | OTHER | 000000312961 | 01 | IN | ANTHEM PROVIDER NUMBER | OTHER | 10590379 | 01 | IN | CAQH NUMBER | OTHER | 200459200 | 05 | IN | MEDICAID |