NPIMap

Organization Active NPI

Charles C Greene MD PHD PA

  • Otolaryngology Physician
  • Jacksonville, FL
National Provider Identifier
1457600769
Registry record updated Aug 3, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Otolaryngology PhysicianTaxonomy code 207Y00000X
Legal business name
CHARLES C GREENE MD PHD PA
Doing business as
Jacksonville ENT Surgery Center
Practice address
11512 Lake Mead Ave
Ste 531
Jacksonville, FL 32256-9733
Phone
(904) 419-2054
Fax
(904) 419-2057
NPI assigned
Aug 31, 2012
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 3, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Charles C GreeneNPI 1306876651
Title
Owner
Phone
(904) 419-2054

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Otolaryngology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Y00000X Primary

Addresses

Primary practice location

11512 Lake Mead Ave
Ste 531
Jacksonville, FL 32256-9733

Mailing address

11512 Lake Mead Ave Unit 531
Jacksonville, FL 32256-9733
Phone (904) 419-2054

Other identifiers 2

IdentifierTypeStateIssuer
008103800MedicaidFL
003PFOtherFLFL BLUE

Other names 1

  • Jacksonville ENT Surgery Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20130307000132 FL Part B Supplier - Clinic/Group Practice 2668627134 Receives reassigned benefits from 9 practitioners
3 other NPIs on this enrollment
Practice locations: Jacksonville, FL

Other NPIs on the same Medicare enrollment 3

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Locations

11512 Lake Mead Ave
Ste 586
Jacksonville, FL 32256

Practitioners & affiliated clinicians

Practitioners 9

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1346371200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1659484800000",
    "number": "1457600769",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11512 LAKE MEAD AVE UNIT 531",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "322569733",
            "telephone_number": "904-419-2054",
            "fax_number": "904-419-2057"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11512 LAKE MEAD AVE",
            "address_2": "STE 531",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "322569733",
            "telephone_number": "904-419-2054",
            "fax_number": "904-419-2057"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CHARLES C GREENE MD PHD PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-08-31",
        "last_updated": "2022-08-03",
        "certification_date": "2022-08-03",
        "status": "A",
        "authorized_official_last_name": "GREENE",
        "authorized_official_first_name": "CHARLES",
        "authorized_official_middle_name": "C",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "904-419-2054"
    },
    "taxonomies": [
        {
            "code": "207Y00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Otolaryngology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "008103800",
            "state": "FL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "FL BLUE",
            "identifier": "003PF",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Jacksonville ENT Surgery Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Jacksonville ENT Surgery Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Jacksonville, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 3, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.