Provider Demographics
NPI:1598014805
Name:CHARLES C GREENE MD PHD PA
Entity Type:Organization
Organization Name:CHARLES C GREENE MD PHD PA
Other - Org Name:JACKSONVILLE ENT SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:C
Authorized Official - Last Name:GREENE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-691-5711
Mailing Address - Street 1:PO BOX 864935
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-4935
Mailing Address - Country:US
Mailing Address - Phone:904-419-2054
Mailing Address - Fax:904-419-2057
Practice Address - Street 1:789 W DUVAL ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-3811
Practice Address - Country:US
Practice Address - Phone:904-419-2054
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-31
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty