1104512938 NPI number — AUSTIN RAY GREENE

Table of content: AUSTIN RAY GREENE (NPI 1104512938)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104512938 NPI number — AUSTIN RAY GREENE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREENE
Provider First Name:
AUSTIN
Provider Middle Name:
RAY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104512938
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/14/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
415 EASTERN AVE APT I
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEESBURG
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45135-9774
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-876-9596
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
313 CHILLICOTHE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HILLSBORO
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45133-7378
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-393-4562
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/14/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: AOD-101YA0400X , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: BH-101YM0800X , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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