Provider Demographics
NPI:1811431323
Name:GREENE AVENUE MEDICAL, PC
Entity type:Organization
Organization Name:GREENE AVENUE MEDICAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/TRUSTEE
Authorized Official - Prefix:
Authorized Official - First Name:ELIDE
Authorized Official - Middle Name:
Authorized Official - Last Name:STERLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-972-7511
Mailing Address - Street 1:1350 GREENE AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11237-4902
Mailing Address - Country:US
Mailing Address - Phone:718-628-8216
Mailing Address - Fax:718-628-4755
Practice Address - Street 1:1350 GREENE AVE FL 2
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237-4902
Practice Address - Country:US
Practice Address - Phone:718-628-8216
Practice Address - Fax:718-628-4755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-19
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY157407261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care