Basic Information
| Provider Information | |||||||||
| NPI: | 1568444313 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREENE | ||||||||
| FirstName: | CHARLENE | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 549 | ||||||||
| Address2: | |||||||||
| City: | IRON MOUNTAIN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498010549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9067741313 | ||||||||
| FaxNumber: | 9067765639 | ||||||||
| Practice Location | |||||||||
| Address1: | 1010 OLIVE AVE | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541210380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7155284775 | ||||||||
| FaxNumber: | 7155285592 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2005 | ||||||||
| LastUpdateDate: | 05/06/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 42172 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 5101009102 | MI | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0852200084 | 01 | MI | BCBS MI | OTHER | P00933500 | 01 | MI | RR MEDICARE | OTHER | 4197165 | 05 | MI | MEDICAID | 30096600 | 05 | WI | MEDICAID |