1205009206 NPI number — GREENE SPECIFIC CHIROPRACTIC CLINIC PC

Table of content: (NPI 1205009206)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205009206 NPI number — GREENE SPECIFIC CHIROPRACTIC CLINIC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREENE SPECIFIC CHIROPRACTIC CLINIC PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1205009206
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
712 E MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PETERSBURG
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47567-1231
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-354-6807
Provider Business Mailing Address Fax Number:
812-354-3036

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
712 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PETERSBURG
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47567-1231
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-354-6807
Provider Business Practice Location Address Fax Number:
812-354-3036
Provider Enumeration Date:
04/10/2008

Additional Information

Authorized Official

Authorized Official Last Name:
GREENE
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
C.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
812-354-6807

Provider Taxonomy Codes

  • Taxonomy code: 111NR0400X , with the licence number:  08001548A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000228713 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 645927 . This is a "ACN GROUP" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000228710 . This is a "ANTHEM BC/BS GROUP" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 327644 . This is a "HEALTHLINK" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200030600 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 350032460 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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