Provider Demographics
NPI:1366466278
Name:GREEN, ADAM S (MSPT)
Entity type:Individual
Prefix:MR
First Name:ADAM
Middle Name:S
Last Name:GREEN
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:467 BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:KENILWORTH
Mailing Address - State:NJ
Mailing Address - Zip Code:07033-1664
Mailing Address - Country:US
Mailing Address - Phone:908-377-4095
Mailing Address - Fax:
Practice Address - Street 1:467 BOULEVARD
Practice Address - Street 2:
Practice Address - City:KENILWORTH
Practice Address - State:NJ
Practice Address - Zip Code:07033-1664
Practice Address - Country:US
Practice Address - Phone:908-377-4095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00915900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA095060Medicare ID - Type Unspecified