MEDICARE: DR. ROGER LEROY GREEN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	R4063	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	52008	OTHER	AR	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1275537912
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROGER LEROY GREEN MD

Provider Business Mailing Address
First Line	:	1200 MCLAIN ST
Second Line	:
City	:	NEWPORT
State	:	AR
Zip	:	72112-3534
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1200 MCLAIN ST
Second Line	:
City	:	NEWPORT
State	:	AR
Zip	:	72112-3534
Country	:	US
Telephone Number	:	870-523-9852
Fax Number	:	870-523-3583

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2005
Last Update Date	:	02/24/2012

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