Provider Demographics
NPI:1215976485
Name:GREEN, ROBERT E (DO)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:E
Last Name:GREEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5059 STROUD RD
Mailing Address - Street 2:
Mailing Address - City:CEDAR HILL
Mailing Address - State:TN
Mailing Address - Zip Code:37032-4802
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1100 BROOKHAVEN RD
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:KY
Practice Address - Zip Code:42134-2746
Practice Address - Country:US
Practice Address - Phone:270-598-4827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02796207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64060049Medicaid
KY000000340428OtherBLUE CROSS BLUE SHIELD
KYP00162404OtherRAILROAD MEDICARE
KYP00162404OtherRAILROAD MEDICARE
0975502Medicare ID - Type Unspecified