=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477132496
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREENE MEDICAL INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2021
-----------------------------------------------------
Last Update Date | 05/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 SHORELINE HWY BLDG B STE 100-1020
-----------------------------------------------------
City | MILL VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94941
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-225-4740
-----------------------------------------------------
Fax | 905-367-8210
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 SHORELINE HWY BLDG B STE 100-1020
-----------------------------------------------------
City | MILL VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94941
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-225-4740
-----------------------------------------------------
Fax | 905-367-8210
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR/CEO
-----------------------------------------------------
Name | DR. AARON J. GREENE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 805-225-4740
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0805X
-----------------------------------------------------
Taxonomy Name | Geriatric Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------