1790753523 NPI number — DR. DOUGLAS STEWART GREEN MD

Table of content: DR. DOUGLAS STEWART GREEN MD (NPI 1790753523)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790753523 NPI number — DR. DOUGLAS STEWART GREEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREEN
Provider First Name:
DOUGLAS
Provider Middle Name:
STEWART
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1790753523
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1199 PLEASANT VALLEY WAY
Provider Second Line Business Mailing Address:
KESSLER INSTITUTE FOR REHABILITATION
Provider Business Mailing Address City Name:
WEST ORANGE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07052
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-325-6210
Provider Business Mailing Address Fax Number:
973-243-6861

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1199 PLEASANT VALLEY WAY
Provider Second Line Business Practice Location Address:
KESSLER INSTITUTE FOR REHABILITATION
Provider Business Practice Location Address City Name:
WEST ORANGE
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07052
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-325-6210
Provider Business Practice Location Address Fax Number:
973-243-6861
Provider Enumeration Date:
03/09/2006

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: 207R00000X , with the licence number:  MA45011 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X , with the licence number: MA45011 , 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: F02745 . This is a "HEALTHNET" identifier . This identifiers is of the category "OTHER".
  • Identifier: 44611 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1948504 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1551579 . This is a "OXFORD INSURANCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 290008079 . This is a "PALMETTO" identifier . This identifiers is of the category "OTHER".




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