Provider Demographics
NPI:1073554986
Name:GREENE, CHARLES HENRY III (MS, PT, ATC)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:HENRY
Last Name:GREENE
Suffix:III
Gender:M
Credentials:MS, PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 S POLK ST
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:MO
Mailing Address - Zip Code:64402-1618
Mailing Address - Country:US
Mailing Address - Phone:660-726-5762
Mailing Address - Fax:660-726-5764
Practice Address - Street 1:203 S POLK ST
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:MO
Practice Address - Zip Code:64402-1618
Practice Address - Country:US
Practice Address - Phone:660-726-5762
Practice Address - Fax:660-726-5764
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO104902225100000X, 2251S0007X
KS1101879225100000X
MO10688622255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Not Answered2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO25783024OtherBLUE CROSS BLUE SHIELD
MO25783024OtherBLUE CROSS BLUE SHIELD