Provider Demographics
NPI:1225007206
Name:GREENWALD, SCOTT HOWARD (MD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:HOWARD
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 1:5555 GLENWOOD HILLS PKWY SE STE 2
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49512-2091
Mailing Address - Country:US
Mailing Address - Phone:616-940-2662
Mailing Address - Fax:616-940-1965
Practice Address - Street 1:2060 EAST PARIS AVE SE STE 200
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-6113
Practice Address - Country:US
Practice Address - Phone:616-940-2662
Practice Address - Fax:616-285-1006
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301092434207LP2900X, 208VP0014X
IN01058148A208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN9107623OtherPHCS PID NUMBER
IN000000312961OtherANTHEM PROVIDER NUMBER
IN10590379OtherCAQH NUMBER
IN200459200Medicaid
INH21983Medicare UPIN
IN200459200Medicaid
INP00143742Medicare PIN
IN000000312961OtherANTHEM PROVIDER NUMBER
IN815510OOMedicare PIN
IN9107623OtherPHCS PID NUMBER
IN224390BMedicare PIN