Healthcare Provider Details

I. General information

NPI: 1043219967
Provider Name (Legal Business Name): MARK LOUIS GREENBERG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4352 MANCHESTER AVE
SAINT LOUIS MO
63110-2138
US

IV. Provider business mailing address

4352 MANCHESTER AVE
SAINT LOUIS MO
63110-2138
US

V. Phone/Fax

Practice location:
  • Phone: 314-481-1615
  • Fax: 314-531-0063
Mailing address:
  • Phone: 314-481-1615
  • Fax: 314-531-0063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number21921
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR7G09
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: