1356469696 NPI number — JOSEPH WATTS GREENE M.D.

Table of content: (NPI 1962433409)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356469696 NPI number — JOSEPH WATTS GREENE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREENE
Provider First Name:
JOSEPH
Provider Middle Name:
WATTS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1356469696
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/27/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 776351
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60677-6351
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-588-9490
Provider Business Mailing Address Fax Number:
502-272-5116

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3810 SPRINGHURST BLVD STE 310
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40241-6162
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-447-5633
Provider Business Practice Location Address Fax Number:
833-974-2507
Provider Enumeration Date:
03/26/2007

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: 207XS0114X , with the licence number:  45850 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , with the licence number: 45850 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000834300 . This is a "ANTHEM - NOS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 7100131720 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 151611 . This is a "SIHO - NOS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 50052927 . This is a "PASPORT - NOS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 201201590 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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