1487631768 NPI number — TRACEY D GREEN MD

Table of content: TRACEY D GREEN MD (NPI 1487631768)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487631768 NPI number — TRACEY D GREEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREEN
Provider First Name:
TRACEY
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1487631768
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/05/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2345 E PRATER WAY
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
SPARKS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89434-9600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
775-356-4547
Provider Business Mailing Address Fax Number:
775-356-4541

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2345 E PRATER WAY
Provider Second Line Business Practice Location Address:
SUITE 207
Provider Business Practice Location Address City Name:
SPARKS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89434-9600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-356-4547
Provider Business Practice Location Address Fax Number:
775-356-4541
Provider Enumeration Date:
12/28/2005

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: 207Q00000X , with the licence number:  7233 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1487631768 . This is a "NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 11040458 . This is a "CAQH" identifier . This identifiers is of the category "OTHER".




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