Provider Demographics
NPI:1063411155
Name:GREATHOUSE, TALYA (MD)
Entity type:Individual
Prefix:DR
First Name:TALYA
Middle Name:
Last Name:GREATHOUSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 W MAIN ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-1347
Mailing Address - Country:US
Mailing Address - Phone:220-564-1706
Mailing Address - Fax:220-564-1707
Practice Address - Street 1:1717 W MAIN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-1347
Practice Address - Country:US
Practice Address - Phone:220-564-1706
Practice Address - Fax:220-564-1707
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-073394207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2137440Medicaid
OHH276620Medicare PIN