Provider Demographics
NPI:1962437632
Name:GREENE, MICHAEL KEITH (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:KEITH
Last Name:GREENE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:101 E WOOD ST STE 401
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3040
Practice Address - Country:US
Practice Address - Phone:864-560-6654
Practice Address - Fax:864-560-7353
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCTL28811208000000X
SC28811207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC288110Medicaid
SC7013843OtherCIGNA
SC20056179OtherFIRST CHOICE
SC576008010-013OtherBCBS
SC7245906OtherAETNA
SC288110Medicaid
SC576008010-013OtherBCBS
SCP00422255Medicare PIN