Individual
DR. BRENT H. GREENWALD
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
3155 CHANNING WAY, SUITE B, IDAHO FALLS, ID 83404-7546
(208) 535-4800
(208) 535-4807
Mailing address
3155 CHANNING WAY, SUITE B, IDAHO FALLS, ID 83404-7546
(208) 535-4800
(208) 535-4807
Taxonomy
Speciality
Code
Description
License number
State
207T00000X
Neurological Surgery Physician
Primary
M-6947
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010001551
BLUE SHIELD
ID
05
—
002786100
—
ID
01
—
76836
BLUE CROSS
ID
01
—
82-0529781
TAX ID NO
ID
01
—
8M987
BLUE CROSS PRACTICE
ID
Enumeration date
06/25/2006
Last updated
07/13/2009
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