1376601393 NPI number — W MICHAEL GREEN, MD INC

Table of content: (NPI 1376601393)

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".




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