Basic Information
| Provider Information | |||||||||
| NPI: | 1962498766 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREENBERG | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | HOWARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 40000 | ||||||||
| Address2: | |||||||||
| City: | VAIL | ||||||||
| State: | CO | ||||||||
| PostalCode: | 816587520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704761110 | ||||||||
| FaxNumber: | 9704706648 | ||||||||
| Practice Location | |||||||||
| Address1: | 108 S FRONTAGE RD W | ||||||||
| Address2: | US BANK BUILDING STE 306 | ||||||||
| City: | VAIL | ||||||||
| State: | CO | ||||||||
| PostalCode: | 816575053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704761110 | ||||||||
| FaxNumber: | 9704706648 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2005 | ||||||||
| LastUpdateDate: | 06/07/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 06/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 23738 | CO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 01237387 | 05 | CO | MEDICAID | 1962498766 | 05 | WY | MEDICAID | 10026280600 | 05 | NE | MEDICAID | 10026280800 | 05 | NE | MEDICAID | 10026281000 | 05 | NE | MEDICAID | 10026283100 | 05 | NE | MEDICAID | 1982948089 | 05 | NE | MEDICAID | 03788075 | 05 | NM | MEDICAID | 10026280700 | 05 | NE | MEDICAID | 10026281200 | 05 | NE | MEDICAID | 201070520A | 05 | KS | MEDICAID |