Basic Information
| Provider Information | |||||||||
| NPI: | 1952793416 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREENBAUM | ||||||||
| FirstName: | BRITTANY | ||||||||
| MiddleName: | SARA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOGER | ||||||||
| OtherFirstName: | BRITTANY | ||||||||
| OtherMiddleName: | SARA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4951 S WHITE MOUNTAIN RD BLDG A | ||||||||
| Address2: | |||||||||
| City: | SHOW LOW | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859017827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9285376700 | ||||||||
| FaxNumber: | 9285322159 | ||||||||
| Practice Location | |||||||||
| Address1: | 4951 S WHITE MOUNTAIN RD BLDG A | ||||||||
| Address2: | |||||||||
| City: | SHOW LOW | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859017827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9285376700 | ||||||||
| FaxNumber: | 9285322159 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2015 | ||||||||
| LastUpdateDate: | 06/24/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 008343 | AZ | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 004117 | 05 | AZ | MEDICAID |