Provider Demographics
NPI:1275181018
Name:GREENE, THOMAS
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:GREENE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 N 4TH ST APT A
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MO
Mailing Address - Zip Code:63435-1316
Mailing Address - Country:US
Mailing Address - Phone:815-238-9456
Mailing Address - Fax:
Practice Address - Street 1:1 COLLEGE HL
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MO
Practice Address - Zip Code:63435-1257
Practice Address - Country:US
Practice Address - Phone:573-288-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-26
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program