Provider Demographics
NPI:1134127665
Name:GREENE, ROBERT WILBUR JR (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:WILBUR
Last Name:GREENE
Suffix:JR
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 1:6005 PARK AVE
Mailing Address - Street 2:SUITE 112
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-5240
Mailing Address - Country:US
Mailing Address - Phone:901-761-5885
Mailing Address - Fax:901-761-5398
Practice Address - Street 1:6005 PARK AVE
Practice Address - Street 2:SUITE 112
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-5240
Practice Address - Country:US
Practice Address - Phone:901-761-5885
Practice Address - Fax:901-761-5398
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2014-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN019597208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN135549OtherBLUECROSSBLUESHIELD TN
TN3047082Medicaid
TN3047082Medicaid
62-1479421OtherTIN
TN3047082Medicare ID - Type Unspecified
TN110051262Medicare ID - Type UnspecifiedRAILROAD MEDICARE