Basic Information
| Provider Information | |||||||||
| NPI: | 1972617249 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREENE | ||||||||
| FirstName: | HOWARD | ||||||||
| MiddleName: | GILBERT | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2305 GEORGIA ST | ||||||||
| Address2: | |||||||||
| City: | LOUISIANA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633532559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737544584 | ||||||||
| FaxNumber: | 5737545280 | ||||||||
| Practice Location | |||||||||
| Address1: | 2305 GEORGIA ST | ||||||||
| Address2: | |||||||||
| City: | LOUISIANA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633532559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737544584 | ||||||||
| FaxNumber: | 5737545280 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 05/21/2008 | ||||||||
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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 | 207Q00000X | 102816 | MO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 203715529 | 05 | MO | MEDICAID | CK7206 | 01 | MEDICARE RAILROAD PIN | OTHER |