Provider Demographics
NPI:1891152930
Name:GREENE, ELISHAH SUSANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:ELISHAH
Middle Name:SUSANNE
Last Name:GREENE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9500 EUCLID AVE # RK2-7
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44195-0001
Mailing Address - Country:US
Mailing Address - Phone:216-346-9605
Mailing Address - Fax:216-636-5956
Practice Address - Street 1:9500 EUCLID AVE # RK2-7
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44195-0001
Practice Address - Country:US
Practice Address - Phone:216-346-9605
Practice Address - Fax:216-636-5956
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-20
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH500004525RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0155623Medicaid
H366771Medicare PIN
H366770Medicare PIN