1881603199 NPI number — RICHARD R GREEN MD

Table of content: RICHARD R GREEN MD (NPI 1881603199)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881603199 NPI number — RICHARD R GREEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREEN
Provider First Name:
RICHARD
Provider Middle Name:
R
Provider Name Prefix Text:
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:
1881603199
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/16/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3340 NORTH CENTER ST #800
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEHI
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84043-7406
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-990-1911
Provider Business Mailing Address Fax Number:
801-990-1912

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5121 S COTTONWOOD STREET
Provider Second Line Business Practice Location Address:
INTERMOUNTAIN MEDICAL CENTER
Provider Business Practice Location Address City Name:
MURRAY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84157
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-507-5248
Provider Business Practice Location Address Fax Number:
801-733-5618
Provider Enumeration Date:
08/05/2006

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: 207L00000X , with the licence number:  84-171901-1205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1502954 . This is a "UMWA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: QM0000075886 . This is a "ALTIUS" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 104848100 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 37785 . This is a "PEHP" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 002086961 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 107007151101 . This is a "IHC" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 20152 . This is a "DESERET MUTUAL" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 2090168 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 870545614GR2 . This is a "EDUCATORS MUTUAL" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: TPRA06891 . This is a "MOLINA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 553237 . This is a "HEALTHY U" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 804072500 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8597445 . This is a "WORKERS COMP FUND" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 828204 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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