Provider Demographics
NPI:1639258288
Name:GREENE, EDWARD GLENDON (MPH, PT)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:GLENDON
Last Name:GREENE
Suffix:
Gender:M
Credentials:MPH, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1456 HIDEAWAY LN
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-9711
Mailing Address - Country:US
Mailing Address - Phone:269-408-0876
Mailing Address - Fax:
Practice Address - Street 1:2500 NILES RD
Practice Address - Street 2:STE 8
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-3237
Practice Address - Country:US
Practice Address - Phone:269-428-7150
Practice Address - Fax:269-428-7152
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD2576225100000X
MI5501006499225100000X
CAPT41112225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650A111540OtherBCBSM
MA17498OtherPT LICENCE NUMBER MA
MI5501006499OtherPT LICENCE NUMBER MI
MI650A111540OtherBCBSM
MI0P04810Medicare PIN