Provider Demographics
NPI:1710172861
Name:GREENE UROLOGICAL CENTER P.A.
Entity Type:Organization
Organization Name:GREENE UROLOGICAL CENTER P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:GREENE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-426-2565
Mailing Address - Street 1:308 PALMETTO ST
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-7136
Mailing Address - Country:US
Mailing Address - Phone:386-426-2565
Mailing Address - Fax:
Practice Address - Street 1:308 PALMETTO ST
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-7136
Practice Address - Country:US
Practice Address - Phone:386-426-2565
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GREENE UROLOGICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-12
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL379897600Medicaid
FL379897600Medicaid
FL1710172861Medicare PIN