Provider Demographics
NPI:1487693420
Name:GREEN, HEATHER C (MD)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:C
Last Name:GREEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:CROMIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 23229
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42304-3229
Mailing Address - Country:US
Mailing Address - Phone:270-688-1330
Mailing Address - Fax:270-688-1338
Practice Address - Street 1:1325 TRIPLETT ST # B
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-3163
Practice Address - Country:US
Practice Address - Phone:270-688-4325
Practice Address - Fax:270-687-4322
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39866207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300011418Medicaid
KY64116429Medicaid
KYP00912953OtherRAILROAD MEDICARE
KYI12035Medicare UPIN
OH2622433Medicaid
KY64116429Medicaid
KYK067974Medicare PIN
KY0398234Medicare PIN