Healthcare Provider Details

I. General information

NPI: 1922044163
Provider Name (Legal Business Name): GERALD S GREEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 NW 22ND AVE
PORTLAND OR
97210-3025
US

IV. Provider business mailing address

PO BOX 10768
PORTLAND OR
97296-0768
US

V. Phone/Fax

Practice location:
  • Phone: 503-413-7711
  • Fax: 503-227-0218
Mailing address:
  • Phone: 503-227-2400
  • Fax: 503-227-0218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD7312
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: