Provider Demographics
NPI:1780613992
Name:MICHAEL E. GREENE MD, LLC
Entity type:Organization
Organization Name:MICHAEL E. GREENE MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:GREENE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-746-3800
Mailing Address - Street 1:PO BOX 26940
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31221-6940
Mailing Address - Country:US
Mailing Address - Phone:478-746-3800
Mailing Address - Fax:478-746-3882
Practice Address - Street 1:682 HEMLOCK ST
Practice Address - Street 2:SUITE 200
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-6883
Practice Address - Country:US
Practice Address - Phone:478-746-3800
Practice Address - Fax:478-746-3882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA034840207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000473943IMedicaid
GA08BBRSQOtherUNKNOWN
GAGRP7284OtherPTAN
GA08BBRSQMedicare ID - Type Unspecified
GA08BBRSQOtherUNKNOWN
GAGRP7284OtherPTAN