1659467223 NPI number — DR. RONA RENELL GREEN DPM

Table of content: DR. RONA RENELL GREEN DPM (NPI 1659467223)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659467223 NPI number — DR. RONA RENELL GREEN DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREEN
Provider First Name:
RONA
Provider Middle Name:
RENELL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
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:
1659467223
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/24/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 188
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAIRBURN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30213-0188
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-964-2201
Provider Business Mailing Address Fax Number:
770-306-9744

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
67 W. CAMPBELLTON ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRBURN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30213
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-964-2201
Provider Business Practice Location Address Fax Number:
770-306-9744
Provider Enumeration Date:
10/04/2006

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: 213E00000X , with the licence number:  000697 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ES0103X , with the licence number: 000697 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 25127 . This is a "COVENTRY GEORGIA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000558467A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 451998 . This is a "BCBS GEORGIA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 51510661 . This is a "AL BLUE CROSS BLUE SHEILD" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 57106 . This is a "TRICARE GEORGIA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 2700177 . This is a "UNITED HEALTH CARE GA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 4355747 . This is a "AETNA GEORGIA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 515129440 . This is a "AL BCBS (ROANOKE OFFICE)" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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