=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407921448
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RONALD JAY GREENBERG DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2006
-----------------------------------------------------
Last Update Date | 08/09/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 731 S WEST ST
-----------------------------------------------------
City | OLNEY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-392-5511
-----------------------------------------------------
Fax | 618-392-2433
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 731 S WEST ST PO BOX 96
-----------------------------------------------------
City | OLNEY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-392-5511
-----------------------------------------------------
Fax | 618-392-2433
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 038004748
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------