Provider Demographics
NPI:1184719072
Name:GREENWAY HEALTHCARE, PLLC
Entity type:Organization
Organization Name:GREENWAY HEALTHCARE, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:G
Authorized Official - Last Name:MIKEAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-667-0335
Mailing Address - Street 1:PO BOX 1303
Mailing Address - Street 2:
Mailing Address - City:N WILKESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28659-1303
Mailing Address - Country:US
Mailing Address - Phone:336-667-0335
Mailing Address - Fax:336-667-4434
Practice Address - Street 1:1404 WILLOW LN
Practice Address - Street 2:
Practice Address - City:N WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28659-3584
Practice Address - Country:US
Practice Address - Phone:336-667-0335
Practice Address - Fax:336-667-4434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC31264207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5905127Medicaid
NC018KCOtherBCBS
NC5905127Medicaid