Provider Demographics
NPI:1487700506
Name:GREEN, MICHAEL D (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:D
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:497 BEAHAN RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14624-3403
Mailing Address - Country:US
Mailing Address - Phone:585-247-5400
Mailing Address - Fax:585-319-4124
Practice Address - Street 1:497 BEAHAN RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14624-3403
Practice Address - Country:US
Practice Address - Phone:585-247-5400
Practice Address - Fax:585-319-4124
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2017-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY176492208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY101264DLOtherPREFERRED CARE
NYAETNAOther4562184
NY01172072Medicaid
NY6550OtherBLUE CROSS & BLUE SHIELD
NY010176492OtherBLUE CHOICE
NY000922968001OtherHEALTH NOW