Provider Demographics
NPI:1346421047
Name:GREEN, RICHARD A (PT)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:A
Last Name:GREEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5350 GULF OF MEXICO DRIVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:LONGBOAT KEY
Mailing Address - State:FL
Mailing Address - Zip Code:34228
Mailing Address - Country:US
Mailing Address - Phone:941-387-8450
Mailing Address - Fax:941-387-9718
Practice Address - Street 1:5350 GULF OF MEXICO DRIVE
Practice Address - Street 2:SUITE 205
Practice Address - City:LONGBOAT KEY
Practice Address - State:FL
Practice Address - Zip Code:34228
Practice Address - Country:US
Practice Address - Phone:941-387-8450
Practice Address - Fax:941-387-9718
Is Sole Proprietor?:No
Enumeration Date:2007-11-21
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT1733225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
E4656ZMedicare PIN