Healthcare Provider Details

I. General information

NPI: 1922068659
Provider Name (Legal Business Name): WILLIAM EDWIN GREEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2006
Last Update Date: 12/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 MEDICAL PARK RD SUITE 103
COLUMBIA SC
29203-8003
US

IV. Provider business mailing address

15 MEDICAL PARK RD SUITE 300
COLUMBIA SC
29203-8003
US

V. Phone/Fax

Practice location:
  • Phone: 803-434-4300
  • Fax: 803-434-4351
Mailing address:
  • Phone: 803-434-4300
  • Fax: 803-434-4351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number17477
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number17477
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: