Organization
CHARLES C GREENE MD PHD PA
Active
Other names
Jacksonville ENT Surgery Center
Organization subpart
No
Provider details
NPI number
Authorized official
CHARLES C GREENE (OWNER)
(904) 419-2054
Entity
Organization
Contact information
Practice address
11512 LAKE MEAD AVE, STE 531, JACKSONVILLE, FL 32256-9733
(904) 419-2054
(904) 419-2057
Mailing address
11512 LAKE MEAD AVE UNIT 531, JACKSONVILLE, FL 32256-9733
(904) 419-2054
(904) 419-2057
Taxonomy
Speciality
Code
Description
License number
State
207Y00000X
Otolaryngology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
003PF
FL BLUE
FL
05
—
008103800
—
FL
Enumeration date
08/31/2012
Last updated
08/03/2022
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