1477686905 NPI number — DR. RAYMOND HOWARD GREEN DO

Table of content: DR. RAYMOND HOWARD GREEN DO (NPI 1477686905)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477686905 NPI number — DR. RAYMOND HOWARD GREEN DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREEN
Provider First Name:
RAYMOND
Provider Middle Name:
HOWARD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1477686905
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4735 OGLETOWN STANTON RD
Provider Second Line Business Mailing Address:
MAP 2, SUITE 3301
Provider Business Mailing Address City Name:
NEWARK
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19713-2072
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4735 OGLETOWN STANTON ROAD
Provider Second Line Business Practice Location Address:
MEDICAL ARTS PAVILION 2, SUITE 3301
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19713-2067
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-623-4370
Provider Business Practice Location Address Fax Number:
856-342-2817
Provider Enumeration Date:
03/13/2007

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: 208600000X , with the licence number:  C7-0002936 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0102X , with the licence number: MB08839000 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0102X , with the licence number: C2-0011822 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: MB08839000 . This is a "STATE LICENSE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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