Basic Information
| Provider Information | |||||||||
| NPI: | 1669451894 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREENHOUSE | ||||||||
| FirstName: | SANFORD | ||||||||
| MiddleName: | ALAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 355 | ||||||||
| Address2: | |||||||||
| City: | GALES FERRY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063350355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604647253 | ||||||||
| FaxNumber: | 8604647404 | ||||||||
| Practice Location | |||||||||
| Address1: | 1527 ROUTE 12 | ||||||||
| Address2: | |||||||||
| City: | GALES FERRY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063351800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604647253 | ||||||||
| FaxNumber: | 8604647404 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2006 | ||||||||
| LastUpdateDate: | 11/30/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 020530 | CT | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001205301 | 05 | CT | MEDICAID |