Provider Demographics
NPI:1902969041
Name:GREENHURST PC
Entity Type:Organization
Organization Name:GREENHURST PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN
Authorized Official - Prefix:
Authorized Official - First Name:EDMON
Authorized Official - Middle Name:L
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-317-9202
Mailing Address - Street 1:PO BOX 14189
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37814-0002
Mailing Address - Country:US
Mailing Address - Phone:423-317-9202
Mailing Address - Fax:423-317-9206
Practice Address - Street 1:1410 DOYAL DR
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37814-6108
Practice Address - Country:US
Practice Address - Phone:423-317-9202
Practice Address - Fax:423-317-9206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3729559Medicaid
TN3729559Medicaid