Provider Demographics
NPI:1548440407
Name:GREENVILLE SURGICAL, PLLC
Entity type:Organization
Organization Name:GREENVILLE SURGICAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:HASTINGS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:252-754-8370
Mailing Address - Street 1:1011 W H SMITH BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-3787
Mailing Address - Country:US
Mailing Address - Phone:252-754-8370
Mailing Address - Fax:252-754-8387
Practice Address - Street 1:1011 W H SMITH BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-3787
Practice Address - Country:US
Practice Address - Phone:252-754-8370
Practice Address - Fax:252-754-8387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-08
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC98008942086S0129X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891149VMedicaid
NC891149VMedicaid
NCG75136Medicare UPIN