Healthcare Provider Details

I. General information

NPI: 1497855803
Provider Name (Legal Business Name): BOB H GREENE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 06/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4303 MICHIGAN AVE
MANITOWOC WI
54220-3066
US

IV. Provider business mailing address

PO BOX 2290
MANITOWOC WI
54221-2290
US

V. Phone/Fax

Practice location:
  • Phone: 920-320-4300
  • Fax: 920-684-5146
Mailing address:
  • Phone: 920-320-2840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number40942
License Number StateWI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier32563300
Identifier TypeMEDICAID
Identifier StateWI
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: