Healthcare Provider Details

I. General information

NPI: 1295123826
Provider Name (Legal Business Name): MONTVERDE MEDICAL CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2015
Last Update Date: 01/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17434 8TH STREET
MONTVERDE FL
34756
US

IV. Provider business mailing address

27 RIVER RIDGE TRL
ORMOND BEACH FL
32174-4341
US

V. Phone/Fax

Practice location:
  • Phone: 386-871-8535
  • Fax: 386-269-4328
Mailing address:
  • Phone: 386-871-8535
  • Fax: 386-269-4328

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0005X
TaxonomyUndersea and Hyperbaric Medicine (Emergency Medicine) Physician
License NumberME92697
License Number StateFL

VIII. Authorized Official

Name: DR. URIL GREENE
Title or Position: OWNER/PRESIDENT
Credential: M.D.
Phone: 386-871-8535