Healthcare Provider Details

I. General information

NPI: 1154852085
Provider Name (Legal Business Name): BENJAMIN GREEN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2017
Last Update Date: 10/14/2025
Certification Date: 10/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

495 HIGHLAND BLVD STE 103
COATESVILLE PA
19320-5822
US

IV. Provider business mailing address

495 HIGHLAND BLVD STE 103
COATESVILLE PA
19320-5822
US

V. Phone/Fax

Practice location:
  • Phone: 610-343-3668
  • Fax: 610-365-4991
Mailing address:
  • Phone: 610-343-3668
  • Fax: 610-365-4991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberSC007230
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number0103301302
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: