=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598014805
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHARLES C GREENE MD PHD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2012
-----------------------------------------------------
Last Update Date | 06/04/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 789 W DUVAL ST
-----------------------------------------------------
City | LAKE CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32055-3811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-419-2054
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 864935
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32886-4935
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-419-2054
-----------------------------------------------------
Fax | 904-419-2057
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CHARLES C GREENE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 912-691-5711
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------