=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356538607
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREENWICH NEUROLOGY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2007
-----------------------------------------------------
Last Update Date | 10/01/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 49 LAKE AVE SUITE 2-27
-----------------------------------------------------
City | GREENWICH
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06830-4501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-869-6446
-----------------------------------------------------
Fax | 203-869-7401
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 49 LAKE AVE SUITE 2-27
-----------------------------------------------------
City | GREENWICH
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06830-4501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-869-6446
-----------------------------------------------------
Fax | 203-869-7401
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | WALTER A CAMP
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 203-869-6446
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 011739
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------