Provider Demographics
NPI:1144275207
Name:GREENWALD, BOB (MD)
Entity type:Individual
Prefix:
First Name:BOB
Middle Name:
Last Name:GREENWALD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 KINDERKAMACK RD STE 200
Mailing Address - Street 2:
Mailing Address - City:RIVER EDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07661-1931
Mailing Address - Country:US
Mailing Address - Phone:201-488-2660
Mailing Address - Fax:201-489-2812
Practice Address - Street 1:30 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1915
Practice Address - Country:US
Practice Address - Phone:551-996-2200
Practice Address - Fax:201-489-2812
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA049039002085R0202X
PAMD4217512085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0253707Medicaid
NJ117380AVDMedicare PIN
NJ0253707Medicaid