Healthcare Provider Details

I. General information

NPI: 1063693828
Provider Name (Legal Business Name): RICHARD J GREEN MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2007
Last Update Date: 11/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 VINE ST
JOHNSTOWN PA
15901-1518
US

IV. Provider business mailing address

213 VINE ST
JOHNSTOWN PA
15901-1518
US

V. Phone/Fax

Practice location:
  • Phone: 814-535-5841
  • Fax: 814-539-3424
Mailing address:
  • Phone: 814-535-5841
  • Fax: 814-539-3424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD029508E
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberMD029508E
License Number StatePA

VIII. Authorized Official

Name: DR. RICHARD JOSEPH GREEN III
Title or Position: DOCTOR
Credential: MD
Phone: 814-535-5841