Basic Information
Provider Information
NPI: 1003803966
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: GREENSPAN
FirstName: ELLIOTT
MiddleName: I
NamePrefix: DR.
NameSuffix:  
Credential: D.O.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 36123 SCHOOLCRAFT RD
Address2:  
City: LIVONIA
State: MI
PostalCode: 481501216
CountryCode: US
TelephoneNumber: 7344640887
FaxNumber: 7344020254
Practice Location
Address1: 36123 SCHOOLCRAFT RD
Address2:  
City: LIVONIA
State: MI
PostalCode: 481501216
CountryCode: US
TelephoneNumber: 7344640887
FaxNumber: 7344020254
Other Information
ProviderEnumerationDate: 10/05/2005
LastUpdateDate: 04/18/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207R00000X5101005633MIY Allopathic & Osteopathic PhysiciansInternal Medicine 

ID Information
IDTypeStateIssuerDescription
4865778-1105MI MEDICAID
1791545-1105MI MEDICAID
3142396-1105MI MEDICAID
1188028-1105MI MEDICAID


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