Basic Information
| Provider Information | |||||||||
| NPI: | 1366484560 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREENE | ||||||||
| FirstName: | ONAJE | ||||||||
| MiddleName: | DADISI | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 119 AMBULANCE DR | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | CARROLLTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301173857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708369326 | ||||||||
| FaxNumber: | 7708369358 | ||||||||
| Practice Location | |||||||||
| Address1: | 705 DIXIE ST | ||||||||
| Address2: | SUITE 401 | ||||||||
| City: | CARROLLTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301173818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708369326 | ||||||||
| FaxNumber: | 7708369358 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 06/28/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 057079 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 346632641G | 05 | GA | MEDICAID | 511I060280 | 01 | GA | MEDICARE PTAN | OTHER |