MEDICARE: DR. MARIANNE ELIZABETH GREENE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	036-086197	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01621061	OTHER	IL	BCBS IL

General Provider Information

NPI Number	:	1255340139
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARIANNE ELIZABETH GREENE M.D.

Provider Business Mailing Address
First Line	:	1910 N BURLING ST
Second Line	:	UNIT A
City	:	CHICAGO
State	:	IL
Zip	:	60614-5124
Country	:	US
Telephone Number	:	773-505-9892
Fax Number	:

Provider Business Practice Location Address
First Line	:	1910 N BURLING ST
Second Line	:	UNIT A
City	:	CHICAGO
State	:	IL
Zip	:	60614-5124
Country	:	US
Telephone Number	:	773-505-9892
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/07/2006
Last Update Date	:	08/03/2011

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