Healthcare Provider Details

I. General information

NPI: 1164468120
Provider Name (Legal Business Name): GARY A GREENSPAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 06/13/2024
Certification Date: 06/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 WARRRENSVILLE CNTR ROAD #200
WARRENSVILLE HTS OH
44122
US

IV. Provider business mailing address

PO BOX 660
MENTOR OH
44061-0660
US

V. Phone/Fax

Practice location:
  • Phone: 216-752-7676
  • Fax: 216-295-8041
Mailing address:
  • Phone: 440-854-0217
  • Fax: 440-516-3783

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number054667
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: