1891004420 NPI number — PETER GREEN MD PA

Table of content: (NPI 1891004420)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891004420 NPI number — PETER GREEN MD PA

Organization/Personal Information

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

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:
1891004420
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/30/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6337
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76115-0337
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-293-2944
Provider Business Mailing Address Fax Number:
817-293-2039

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11801 SOUTH FWY
Provider Second Line Business Practice Location Address:
SUITE 234
Provider Business Practice Location Address City Name:
BURLESON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76028-7021
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-293-2944
Provider Business Practice Location Address Fax Number:
817-293-2039
Provider Enumeration Date:
09/30/2010

Additional Information

Authorized Official

Authorized Official Last Name:
GREEN
Authorized Official First Name:
PETER
Authorized Official Middle Name:
Authorized Official Title or Position:
MD
Authorized Official Telephone Number:
817-293-2944

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  F8497 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com