1063662310 NPI number — W MICHAEL GREEN, MD INC

Table of content: (NPI 1063662310)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063662310 NPI number — W MICHAEL GREEN, MD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
W MICHAEL GREEN, MD INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
WILLAM M GREEN, MD INC
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063662310
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 986
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAMARILLO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93011-0986
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-482-6233
Provider Business Mailing Address Fax Number:
805-389-5883

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2309 ANTONIO AVE
Provider Second Line Business Practice Location Address:
PATHOLOGY DEPARTMENT
Provider Business Practice Location Address City Name:
CAMARILLO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93010-1414
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-389-5878
Provider Business Practice Location Address Fax Number:
805-389-5883
Provider Enumeration Date:
09/23/2008

Additional Information

Authorized Official

Authorized Official Last Name:
GREEN
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
805-482-6233

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0102X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GR0059650 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00G19218 . This is a "BLUE SHIELD" identifier . This identifiers is of the category "OTHER".




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