1558358739 NPI number — DR. WILLIAM J GREEN DPM

Table of content: DR. WILLIAM J GREEN DPM (NPI 1558358739)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558358739 NPI number — DR. WILLIAM J GREEN DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREEN
Provider First Name:
WILLIAM
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1558358739
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111 MAPLE GROVE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUMBERTON
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08048-4617
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
609-386-0217
Provider Business Mailing Address Fax Number:
609-386-2205

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
319 W BROAD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURLINGTON
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08016-1343
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-386-0217
Provider Business Practice Location Address Fax Number:
609-386-2205
Provider Enumeration Date:
10/03/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213EP1101X , with the licence number:  25MD002143 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1154339 . This is a "CIGNA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 5486904 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: P3800567 . This is a "OXFORD" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0040897000 . This is a "AMERIHEALTH" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 1094025 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0183361 . This is a "AETNA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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