Healthcare Provider Details

I. General information

NPI: 1417178187
Provider Name (Legal Business Name): CLYDE O. GREEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 01/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

841 MULBERRY ST
MACON GA
31201-6756
US

IV. Provider business mailing address

841 MULBERRY ST
MACON GA
31201-6756
US

V. Phone/Fax

Practice location:
  • Phone: 478-741-6554
  • Fax: 478-743-7052
Mailing address:
  • Phone: 478-741-6554
  • Fax: 478-743-7052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number30072
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number30072
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: