1598742827 NPI number — DR. GLENN D GREEN O.D.

Table of content: DR. GLENN D GREEN O.D. (NPI 1598742827)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598742827 NPI number — DR. GLENN D GREEN O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREEN
Provider First Name:
GLENN
Provider Middle Name:
D
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
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:
1598742827
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3882 N FOXTAIL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POST FALLS
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83854-0264
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-739-6887
Provider Business Mailing Address Fax Number:
208-457-7008

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3882 N FOXTAIL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POST FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83854-0264
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-739-6887
Provider Business Practice Location Address Fax Number:
208-457-7008
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: 152W00000X , with the licence number:  OD00001910 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: ODP-100616 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 03118 . This is a "REGENCE OF WA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0078676 . This is a "DEPT OF LABOR & INDUSTRIE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 2022267 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 410040896 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 431510001 . This is a "GROUP HEALTH" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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