Provider Demographics
NPI:1528216835
Name:GREENE FAMILY MEDICINE, PLLC
Entity Type:Organization
Organization Name:GREENE FAMILY MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARJORIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KETZAK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:607-427-4588
Mailing Address - Street 1:20 N CHENANGO ST
Mailing Address - Street 2:
Mailing Address - City:GREENE
Mailing Address - State:NY
Mailing Address - Zip Code:13778-1131
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:29 N CHENANGO ST
Practice Address - Street 2:
Practice Address - City:GREENE
Practice Address - State:NY
Practice Address - Zip Code:13778-1139
Practice Address - Country:US
Practice Address - Phone:607-427-4588
Practice Address - Fax:607-656-5015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-29
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care