Provider Demographics
NPI:1104063197
Name:GREEN, ADRIEL R (DPT)
Entity type:Individual
Prefix:
First Name:ADRIEL
Middle Name:R
Last Name:GREEN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 YELLOW WOOD WAY
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-7126
Mailing Address - Country:US
Mailing Address - Phone:304-255-2376
Mailing Address - Fax:304-255-7120
Practice Address - Street 1:9 YELLOW WOOD WAY
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-7126
Practice Address - Country:US
Practice Address - Phone:304-255-2376
Practice Address - Fax:304-255-7120
Is Sole Proprietor?:No
Enumeration Date:2009-01-13
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV002735225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV002097180OtherBLUE CROSS BLUE SHIELD
371681200OtherFEDERAL WORKERS COMP
WV3810014501Medicaid
WV001710560OtherBLUE CROSS BLUE SHIELD
WV9241425OtherAETNA
WVP00813687OtherRR MEDICARE
WV1516805OtherUMWA
WV3810014501Medicaid
WV9241425OtherAETNA
WV4284321Medicare UPIN