Provider Demographics
NPI:1215049762
Name:GREEN, RICHARD JOSEPH III (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:JOSEPH
Last Name:GREEN
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD029508207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1364035OtherUMWA
PA252575OtherUPMC
PA1035506OtherGATEWAY HEALTH PLAN
PA0011025510001Medicaid
PA001696852OtherHIGHMARK
PA0011025510001Medicaid
PA1035506OtherGATEWAY HEALTH PLAN