Healthcare Provider Details

I. General information

NPI: 1407857477
Provider Name (Legal Business Name): COREY S. GREENWALD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 02/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2711 IRVIN WAY SUITE 211
DECATUR GA
30030-5405
US

IV. Provider business mailing address

2711 IRVIN WAY SUITE 211
DECATUR GA
30030-5405
US

V. Phone/Fax

Practice location:
  • Phone: 404-501-0001
  • Fax: 404-501-0023
Mailing address:
  • Phone: 404-501-0001
  • Fax: 404-501-0023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number041130
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: