=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770537789
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GEORGE E GREENBERG MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2004 1ST AVE SUITE A
-----------------------------------------------------
City | DODGE CITY
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67801-2623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-225-1033
-----------------------------------------------------
Fax | 620-227-8491
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2004 1ST AVE SUITE A
-----------------------------------------------------
City | DODGE CITY
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67801-2623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-225-1033
-----------------------------------------------------
Fax | 620-227-8491
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 0414629
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------