Basic Information
| Provider Information | |||||||||
| NPI: | 1598151573 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREENKY | ||||||||
| FirstName: | MAX | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5824 WIDEWATERS PKWY | ||||||||
| Address2: | |||||||||
| City: | EAST SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130573072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3152513105 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5719 WIDEWATERS PKWY STE 2 | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132141877 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3152513100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2015 | ||||||||
| LastUpdateDate: | 09/13/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 310185 | NY | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 06556743 | 05 | NY | MEDICAID |