Provider Demographics
NPI:1073618732
Name:GREENVILLE NEUROLOGY CONSULTANTS, PA
Entity Type:Organization
Organization Name:GREENVILLE NEUROLOGY CONSULTANTS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GENNA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:LYNN
Authorized Official - Suffix:
Authorized Official - Credentials:CMOM
Authorized Official - Phone:864-242-9662
Mailing Address - Street 1:4 OLD GROVE RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-4712
Mailing Address - Country:US
Mailing Address - Phone:864-242-9662
Mailing Address - Fax:864-467-0980
Practice Address - Street 1:4 OLD GROVE RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4712
Practice Address - Country:US
Practice Address - Phone:864-242-9662
Practice Address - Fax:864-467-0980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC178362084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP1244Medicaid
SCQ29590Medicaid
SCGP1244Medicaid
SCD28975Medicare UPIN
SCD289755973Medicare ID - Type UnspecifiedDR. BOOR IDENTIF # MC