1053379537 NPI number — DR. DWAYNE ERIC GREENE MD

Table of content: DR. DWAYNE ERIC GREENE MD (NPI 1053379537)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053379537 NPI number — DR. DWAYNE ERIC GREENE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREENE
Provider First Name:
DWAYNE
Provider Middle Name:
ERIC
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1053379537
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/02/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
825 10TH ST NW APT 1179
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WASHINGTON
Provider Business Mailing Address State Name:
DC
Provider Business Mailing Address Postal Code:
20001-5096
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-536-3607
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
SENTARA CAREPLEX HOSPITAL
Provider Second Line Business Practice Location Address:
3000 COLISEUM DRIVE
Provider Business Practice Location Address City Name:
HAMPTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23666
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-736-2008
Provider Business Practice Location Address Fax Number:
757-736-1029
Provider Enumeration Date:
05/03/2006

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: 207P00000X , with the licence number:  057630 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: 74892 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: 51588 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 533972530A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 074892 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 3083411 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: J11666 . This is a "BS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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