Provider Demographics
NPI:1912963505
Name:GREENE ISABELL MED ASSOC INC
Entity Type:Organization
Organization Name:GREENE ISABELL MED ASSOC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:BRICE
Authorized Official - Last Name:GREENE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:773-734-1577
Mailing Address - Street 1:7906 S CRANDON AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-1146
Mailing Address - Country:US
Mailing Address - Phone:773-734-1577
Mailing Address - Fax:773-734-1077
Practice Address - Street 1:7906 S CRANDON AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-1146
Practice Address - Country:US
Practice Address - Phone:773-734-1577
Practice Address - Fax:773-734-1077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-24
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036057667207Q00000X
IL036051858207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209520OtherMEDICARE GROUP PROVIDER