Provider Demographics
NPI:1568444313
Name:GREENE, CHARLENE M (DO)
Entity Type:Individual
Prefix:DR
First Name:CHARLENE
Middle Name:M
Last Name:GREENE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-0549
Mailing Address - Country:US
Mailing Address - Phone:906-774-1313
Mailing Address - Fax:906-776-5639
Practice Address - Street 1:1010 OLIVE AVE
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:WI
Practice Address - Zip Code:54121-0380
Practice Address - Country:US
Practice Address - Phone:715-528-4775
Practice Address - Fax:715-528-5592
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI42172207Q00000X
MI5101009102207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0852200084OtherBCBS MI
MIP00933500OtherRR MEDICARE
MI4197165Medicaid
WI30096600Medicaid
E37382Medicare UPIN
MIP00933500OtherRR MEDICARE
WI210100004Medicare PIN