MEDICARE: KIRBY ARNESTO 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	207P00000X	Emergency Medicine Physician	014738	LA
2	207R00000X	Internal Medicine Physician	6053966-1205	UT

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1619909744
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIRBY ARNESTO GREEN MD

Provider Business Mailing Address
First Line	:	2290 S 1300 E
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-2831
Country	:	US
Telephone Number	:	801-474-0800
Fax Number	:	801-467-1126

Provider Business Practice Location Address
First Line	:	2290 SOUTH 1300 EAST
Second Line	:	MEDICAL MARTS
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-2831
Country	:	US
Telephone Number	:	801-474-0800
Fax Number	:	810-467-1126

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

Provider Enumeration Date	:	07/07/2006
Last Update Date	:	11/07/2007

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