1235123191 NPI number — DR. WAVERLY SYNDOR GREEN III MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235123191 NPI number — DR. WAVERLY SYNDOR GREEN III MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREEN
Provider First Name:
WAVERLY
Provider Middle Name:
SYNDOR
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
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:
1235123191
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/24/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
580 SAINT JOHNSBURY RD
Provider Second Line Business Mailing Address:
SUITE 25
Provider Business Mailing Address City Name:
LITTLETON
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03561-3437
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-259-7780
Provider Business Mailing Address Fax Number:
603-444-2769

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
580 SAINT JOHNSBURY RD
Provider Second Line Business Practice Location Address:
SUITE 25
Provider Business Practice Location Address City Name:
LITTLETON
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03561-3437
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-259-7780
Provider Business Practice Location Address Fax Number:
603-444-2769
Provider Enumeration Date:
09/07/2005

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: 207RP1001X , with the licence number:  9300133 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X , with the licence number: 15701 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 29211 . This is a "BCBS-IND." identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 7937060 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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