Healthcare Provider Details

I. General information

NPI: 1366193310
Provider Name (Legal Business Name): KODY GREEN CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2022
Last Update Date: 03/15/2023
Certification Date: 03/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3595 COLUMBUS RD
CENTERBURG OH
43011-7088
US

IV. Provider business mailing address

3595 COLUMBUS RD
CENTERBURG OH
43011-7088
US

V. Phone/Fax

Practice location:
  • Phone: 740-625-6234
  • Fax:
Mailing address:
  • Phone: 740-625-6234
  • Fax: 740-625-5806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberAPRN.CNP.0030515
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: