Provider Demographics
NPI:1063693828
Name:RICHARD J GREEN MD PC
Entity type:Organization
Organization Name:RICHARD J GREEN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:814-535-5841
Mailing Address - Street 1:213 VINE ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15901-1518
Mailing Address - Country:US
Mailing Address - Phone:814-535-5841
Mailing Address - Fax:814-539-3424
Practice Address - Street 1:213 VINE ST
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15901-1518
Practice Address - Country:US
Practice Address - Phone:814-535-5841
Practice Address - Fax:814-539-3424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-21
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD029508E261QP2300X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty