1508951856 NPI number — REBECCA GREEN

Table of content: REBECCA GREEN (NPI 1508951856)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508951856 NPI number — REBECCA GREEN

Organization/Personal Information

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

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SHARP
Provider Other First Name:
REBECCA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1508951856
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/23/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2424 32ND AVE S
Provider Second Line Business Mailing Address:
STE 202
Provider Business Mailing Address City Name:
GRAND FORKS
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58201-6545
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-746-6336
Provider Business Mailing Address Fax Number:
701-772-1030

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2424 32ND AVE S
Provider Second Line Business Practice Location Address:
STE 202
Provider Business Practice Location Address City Name:
GRAND FORKS
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58201-6545
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-746-6336
Provider Business Practice Location Address Fax Number:
701-772-1030
Provider Enumeration Date:
10/03/2006

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: 103TC0700X , with the licence number:  270 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 18288 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 24743 . This is a "BLUECROSSBLUESHIELD OF ND" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 1451969 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 309K9GR . This is a "BLUECROSSBLUESHIELD OF MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 61-66614 . This is a "UBH" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 498806 . This is a "VALUE OPTIONS" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".




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