Provider Demographics
NPI:1316946544
Name:GREEN, BOB E (MD)
Entity type:Individual
Prefix:DR
First Name:BOB
Middle Name:E
Last Name:GREEN
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Gender:M
Credentials:MD
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Mailing Address - Street 1:10308 STATE LINE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66206-2658
Mailing Address - Country:US
Mailing Address - Phone:913-381-7117
Mailing Address - Fax:913-383-1316
Practice Address - Street 1:19550 E 39TH ST S
Practice Address - Street 2:SUITE 227
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64057-2303
Practice Address - Country:US
Practice Address - Phone:816-795-9716
Practice Address - Fax:816-795-6358
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2022-06-14
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Provider Licenses
StateLicense IDTaxonomies
MOMO112759207RC0000X
KS04-25504207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100286810HMedicaid
MO1316946544Medicaid
MO208692103Medicaid
KS100286810HMedicaid
MOP00658794Medicare PIN
MO4017870Medicare ID - Type Unspecified
MO1316946544Medicaid
MO208692103Medicaid