Provider Demographics
NPI:1457600769
Name:CHARLES C GREENE MD PHD PA
Entity Type:Organization
Organization Name:CHARLES C GREENE MD PHD PA
Other - Org Name:JACKSONVILLE ENT SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:C
Authorized Official - Last Name:GREENE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-419-2054
Mailing Address - Street 1:11512 LAKE MEAD AVE UNIT 531
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-9733
Mailing Address - Country:US
Mailing Address - Phone:904-419-2054
Mailing Address - Fax:904-419-2057
Practice Address - Street 1:11512 LAKE MEAD AVE
Practice Address - Street 2:STE 531
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-9733
Practice Address - Country:US
Practice Address - Phone:904-419-2054
Practice Address - Fax:904-419-2057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-31
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008103800Medicaid
FL003PFOtherFL BLUE
FL003PFOtherFL BLUE
FL008103800Medicaid