Basic Information
Provider Information | |||||||||
NPI: | 1902165301 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JOHNSON GREENE | ||||||||
FirstName: | LYNN | ||||||||
MiddleName: | R. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GREENE | ||||||||
OtherFirstName: | LYNN | ||||||||
OtherMiddleName: | R. | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 22487 | ||||||||
Address2: |   | ||||||||
City: | GREEN BAY | ||||||||
State: | WI | ||||||||
PostalCode: | 543052487 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9204457226 | ||||||||
FaxNumber: | 9204457238 | ||||||||
Practice Location | |||||||||
Address1: | 440 WOODWARD AVE | ||||||||
Address2: |   | ||||||||
City: | IRON MOUNTAIN | ||||||||
State: | MI | ||||||||
PostalCode: | 498014631 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9067769040 | ||||||||
FaxNumber: | 9067745950 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/07/2012 | ||||||||
LastUpdateDate: | 05/28/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/28/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 33110 | AL | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 4301502375 | MI | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 1091487326 | 01 |   | AMERICAN BOARD OF FAMILY MEDICINE | OTHER |