Healthcare Provider Details

I. General information

NPI: 1538587928
Provider Name (Legal Business Name): YITZCHOK GREENBERG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2014
Last Update Date: 02/18/2025
Certification Date: 02/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22700 SHEVINGTON DR
SOUTHFIELD MI
48034-2143
US

IV. Provider business mailing address

22700 SHEVINGTON DR
SOUTHFIELD MI
48034-2143
US

V. Phone/Fax

Practice location:
  • Phone: 215-948-2582
  • Fax:
Mailing address:
  • Phone: 215-948-2582
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number100883
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number4301501866
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number01095117A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: