1376601393 NPI number — W MICHAEL GREEN, MD INC

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 1376601393 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:
WM MICHAEL 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:
1376601393
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 25420
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VENTURA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93002-2277
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-650-5910
Provider Business Mailing Address Fax Number:
805-650-5972

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 N ROSE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OXNARD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93030-3722
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-988-2644
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GREEN
Authorized Official First Name:
WM
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
805-988-2644

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: ZZZ42071Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0059650 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com