Provider Demographics
NPI:1396165577
Name:JAMES W GREENE MD LLC
Entity type:Organization
Organization Name:JAMES W GREENE MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:WALTER
Authorized Official - Last Name:GREENE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-434-9164
Mailing Address - Street 1:1015 ARTHUR J MOORE DR # 2
Mailing Address - Street 2:
Mailing Address - City:SAINT SIMONS IS
Mailing Address - State:GA
Mailing Address - Zip Code:31522-2206
Mailing Address - Country:US
Mailing Address - Phone:912-434-9164
Mailing Address - Fax:
Practice Address - Street 1:3215 SHRINE RD STE 3
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4300
Practice Address - Country:US
Practice Address - Phone:912-434-9164
Practice Address - Fax:912-434-9386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-25
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA029657207Q00000X
GA261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202G702594OtherMEDICARE GROUP PTAN
GA000382687BMedicaid
GA000382687BMedicaid