Provider Demographics
NPI:1093864662
Name:GREENVILLE INTERNAL MEDICINE
Entity Type:Organization
Organization Name:GREENVILLE INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LEO
Authorized Official - Middle Name:E
Authorized Official - Last Name:WAIVERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:252-830-1680
Mailing Address - Street 1:800 MOYE BLVD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-3777
Mailing Address - Country:US
Mailing Address - Phone:252-830-1680
Mailing Address - Fax:252-830-0926
Practice Address - Street 1:2210 HEMBY LN
Practice Address - Street 2:SUITE 101
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-3773
Practice Address - Country:US
Practice Address - Phone:252-830-1680
Practice Address - Fax:252-830-0926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC56908207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0169EOtherBCBS-NC
NC890169EMedicaid
NC0169EOtherBCBS-NC