1639258288 NPI number — MR. EDWARD GLENDON GREENE MPH, PT

Table of content: MR. EDWARD GLENDON GREENE MPH, PT (NPI 1639258288)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639258288 NPI number — MR. EDWARD GLENDON GREENE MPH, PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREENE
Provider First Name:
EDWARD
Provider Middle Name:
GLENDON
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MPH, PT
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:
1639258288
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/09/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1456 HIDEAWAY LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT JOSEPH
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49085-9711
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-408-0876
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2500 NILES RD
Provider Second Line Business Practice Location Address:
STE 8
Provider Business Practice Location Address City Name:
SAINT JOSEPH
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49085-3237
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-428-7150
Provider Business Practice Location Address Fax Number:
269-428-7152
Provider Enumeration Date:
11/03/2006

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: 225100000X , with the licence number:  2576 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 5501006499 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT41112 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 650A111540 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 17498 . This is a "PT LICENCE NUMBER MA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 5501006499 . This is a "PT LICENCE NUMBER MI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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