Healthcare Provider Details

I. General information

NPI: 1902287220
Provider Name (Legal Business Name): JACOB K GREENBERG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2015
Last Update Date: 04/17/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1044 N MASON RD DEPT NEUROLOGICAL SURGERY, STE 110
SAINT LOUIS MO
63141-6431
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-3577
  • Fax: 314-884-6004
Mailing address:
  • Phone: 314-362-3577
  • Fax: 314-884-6004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number2019012694
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: