1306876651 NPI number — CHARLES C GREENE MD

Table of content: CHARLES C GREENE MD (NPI 1306876651)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306876651 NPI number — CHARLES C GREENE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREENE
Provider First Name:
CHARLES
Provider Middle Name:
C
Provider Name Prefix Text:
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:
1306876651
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/03/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11512 LAKE MEAD AVE UNIT 531
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32256-9733
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-419-2054
Provider Business Mailing Address Fax Number:
904-419-2057

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11512 LAKE MEAD AVE
Provider Second Line Business Practice Location Address:
SUITE 531
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32256-9680
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-419-2054
Provider Business Practice Location Address Fax Number:
904-419-2057
Provider Enumeration Date:
07/03/2006

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: 207Y00000X , with the licence number:  ME82871 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 264139900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 116264900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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