Healthcare Provider Details

I. General information

NPI: 1518256650
Provider Name (Legal Business Name): PATRICK GREEN MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2011
Last Update Date: 12/27/2024
Certification Date: 12/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 W 1180 N SUITE # 5
TOOELE UT
84074
US

IV. Provider business mailing address

134 W 1180 N STE 5
TOOELE UT
84074-1483
US

V. Phone/Fax

Practice location:
  • Phone: 435-248-0333
  • Fax: 435-248-0334
Mailing address:
  • Phone: 435-248-0333
  • Fax: 435-248-0334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. PATRICK NELSON GREEN
Title or Position: OWNER
Credential: MD
Phone: 801-792-7335