Basic Information
Provider Information | |||||||||
NPI: | 1750395349 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GREENBERG | ||||||||
FirstName: | BENJAMIN | ||||||||
MiddleName: | DAVID | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD, PHD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 345 BLACKSTONE BLVD | ||||||||
Address2: |   | ||||||||
City: | PROVIDENCE | ||||||||
State: | RI | ||||||||
PostalCode: | 029064800 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4014556200 | ||||||||
FaxNumber: | 4014556309 | ||||||||
Practice Location | |||||||||
Address1: | 345 BLACKSTONE BLVD | ||||||||
Address2: |   | ||||||||
City: | PROVIDENCE | ||||||||
State: | RI | ||||||||
PostalCode: | 029064800 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4014556200 | ||||||||
FaxNumber: | 4014556309 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/28/2006 | ||||||||
LastUpdateDate: | 05/06/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | MD10212 | RI | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
ID | Type | State | Issuer | Description | 1093831646 | 01 |   | BUTLER HOSPITAL PROFESSIONAL BILLING OFFICE | OTHER | 406544 | 01 | RI | BLUE CHIP | OTHER | 15-44475 | 01 | RI | UNITED BEHAVIORAL HEALTH | OTHER | 21061-2 | 01 | RI | BLUE CROSS | OTHER | 1104801349 | 01 |   | BUTLER HOSPITAL NPI | OTHER |