MEDICARE: KYLE GREEN PT

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	225100000X	Physical Therapist	60040	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1588918114
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KYLE GREEN PT

Provider Business Mailing Address
First Line	:	511 SW 10TH AVE STE 101
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97205-2700
Country	:	US
Telephone Number	:	503-294-7463
Fax Number	:

Provider Business Practice Location Address
First Line	:	4876 NW BETHANY BLVD
Second Line	:	SUITE L-1
City	:	PORTLAND
State	:	OR
Zip	:	97229-9259
Country	:	US
Telephone Number	:	503-466-2254
Fax Number	:	503-466-1143

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

Provider Enumeration Date	:	11/05/2012
Last Update Date	:	08/18/2015

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Directions to “ KYLE GREEN PT” Practice Location

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