Provider Demographics
NPI:1982600458
Name:GREEN, CHARLES PATRICK (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:PATRICK
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:C. PATRICK
Other - Middle Name:
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2121 E HARMONY RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-3400
Mailing Address - Country:US
Mailing Address - Phone:970-221-1000
Mailing Address - Fax:970-297-6860
Practice Address - Street 1:2121 E HARMONY RD
Practice Address - Street 2:UNIT 100
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528-3401
Practice Address - Country:US
Practice Address - Phone:970-221-1000
Practice Address - Fax:970-297-6860
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO37999207RC0000X, 207UN0901X
NE21397207RC0000X
WY6263A207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY114732300Medicaid
NEP00977662OtherMEDICARE RAILROAD PTAN
CO36377066Medicaid
COCOA102397Medicare PIN
G35182Medicare UPIN
CO36377066Medicaid