Provider Demographics
NPI:1295123826
Name:MONTVERDE MEDICAL CLINIC PA
Entity type:Organization
Organization Name:MONTVERDE MEDICAL CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:URIL
Authorized Official - Middle Name:
Authorized Official - Last Name:GREENE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-871-8535
Mailing Address - Street 1:27 RIVER RIDGE TRL
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-4341
Mailing Address - Country:US
Mailing Address - Phone:386-871-8535
Mailing Address - Fax:386-269-4328
Practice Address - Street 1:17434 8TH STREET
Practice Address - Street 2:
Practice Address - City:MONTVERDE
Practice Address - State:FL
Practice Address - Zip Code:34756
Practice Address - Country:US
Practice Address - Phone:386-871-8535
Practice Address - Fax:386-269-4328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-06
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME92697207PE0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric MedicineGroup - Single Specialty