Healthcare Provider Details

I. General information

NPI: 1700855244
Provider Name (Legal Business Name): THOMAS W GREEN III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 03/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

364 WHITE OAK ST
ASHEBORO NC
27203-5434
US

IV. Provider business mailing address

PO BOX 4997
ASHEBORO NC
27204-4997
US

V. Phone/Fax

Practice location:
  • Phone: 336-633-7723
  • Fax:
Mailing address:
  • Phone: 336-629-0816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number200101209
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number01081769A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: