Basic Information
Provider Information | |||||||||
NPI: | 1063453520 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GREENE | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | F. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: | III | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 236 W MAIN ST | ||||||||
Address2: |   | ||||||||
City: | MOUNT STERLING | ||||||||
State: | KY | ||||||||
PostalCode: | 403531348 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8594047686 | ||||||||
FaxNumber: | 8592744459 | ||||||||
Practice Location | |||||||||
Address1: | 225 HOSPITAL DRIVE | ||||||||
Address2: | BLDG B, STE 255 | ||||||||
City: | WINCHESTER | ||||||||
State: | KY | ||||||||
PostalCode: | 40391 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8597442623 | ||||||||
FaxNumber: | 8597449421 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/08/2006 | ||||||||
LastUpdateDate: | 06/17/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/17/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 34919 | KY | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 64349194 | 05 | KY |   | MEDICAID | 000000290315 | 01 | KY | ANTHEM | OTHER |