Provider Demographics
NPI:1306964135
Name:DR MICHAEL R GREEN PC
Entity type:Organization
Organization Name:DR MICHAEL R GREEN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-688-0156
Mailing Address - Street 1:1490 E FOREMASTER DR
Mailing Address - Street 2:260
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-4488
Mailing Address - Country:US
Mailing Address - Phone:435-688-0156
Mailing Address - Fax:435-688-0330
Practice Address - Street 1:1490 E FOREMASTER DR
Practice Address - Street 2:260
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-4488
Practice Address - Country:US
Practice Address - Phone:435-688-0156
Practice Address - Fax:435-688-0330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT287502-1205207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1070560001Medicare NSC
UT000011531Medicare ID - Type Unspecified