Provider Demographics
NPI:1164498473
Name:GREENE, KEVIN PATRICK (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:PATRICK
Last Name:GREENE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:710 MAIN ST
Mailing Address - Street 2:BUILDING 4
Mailing Address - City:PLANTSVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06479-1565
Mailing Address - Country:US
Mailing Address - Phone:860-378-2891
Mailing Address - Fax:860-378-2894
Practice Address - Street 1:710 MAIN ST
Practice Address - Street 2:BUILDING 4
Practice Address - City:PLANTSVILLE
Practice Address - State:CT
Practice Address - Zip Code:06479-1565
Practice Address - Country:US
Practice Address - Phone:860-378-2891
Practice Address - Fax:860-378-2894
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2013-03-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CT036278207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001362780Medicaid
CTG57311Medicare UPIN