Provider Demographics
NPI:1063443893
Name:GREENE, MARK HINDLEY III (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:HINDLEY
Last Name:GREENE
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 W WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-1136
Mailing Address - Country:US
Mailing Address - Phone:217-883-7302
Mailing Address - Fax:217-479-5892
Practice Address - Street 1:1600 WEST WALNUT
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650
Practice Address - Country:US
Practice Address - Phone:217-883-7302
Practice Address - Fax:217-479-5892
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036107120207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036107120Medicaid
D26545Medicare UPIN
IL202075Medicare ID - Type Unspecified