Provider Demographics
NPI:1598757122
Name:GREENE, JEFFREY (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:GREENE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1350 S KINGS DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-2134
Practice Address - Country:US
Practice Address - Phone:704-446-4490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9801289207RC0200X, 207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1598757122Medicaid
NC2258474BOtherMEDICARE PTAN, INDIVIDUAL
SCNC1315Medicaid
NC891069XMedicaid
NC2258474FOtherMEDICARE PTAN, INDIVIDUAL
NC232009OtherMEDICARE PTAN, GROUP
G79885Medicare UPIN
NC232009OtherMEDICARE PTAN, GROUP
NC2258474GMedicare PIN