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NPI Code Detail

MEDICARE: CHARLES C GREENE MD PHD PA

MEDICARE: CHARLES C GREENE MD PHD PA
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
1207Y00000XOtolaryngology Physician

General Provider Information

NPI Number : 1598014805
Entity Type Code : Organization
Provider Name (Legal Business Name) : CHARLES C GREENE MD PHD PA
Provider Business Mailing Address
First Line : PO BOX 864935
Second Line :
City : ORLANDO
State : FL
Zip : 32886-4935
Country : US
Telephone Number : 904-419-2054
Fax Number : 904-419-2057
Provider Business Practice Location Address
First Line : 789 W DUVAL ST
Second Line :
City : LAKE CITY
State : FL
Zip : 32055-3811
Country : US
Telephone Number : 904-419-2054
Fax Number :
Authorized Official
Title or Position : OWNER
Name : CHARLES C GREENE
Credential :
Telephone Number : 912-691-5711
Provider Enumeration Date : 08/31/2012
Last Update Date : 06/04/2013

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