Healthcare Provider Details

I. General information

NPI: 1053187310
Provider Name (Legal Business Name): PATRICK GREEN MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2023
Last Update Date: 01/14/2026
Certification Date: 01/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 S TOOELE BLVD
TOOELE UT
84074-2093
US

IV. Provider business mailing address

30 S TOOELE BLVD
TOOELE UT
84074-2093
US

V. Phone/Fax

Practice location:
  • Phone: 435-241-7778
  • Fax: 435-248-0334
Mailing address:
  • Phone: 435-248-0333
  • Fax: 435-248-0334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: PATRICK NELSON GREEN
Title or Position: MEDICAL DIRECTOR/OWNER
Credential: MD
Phone: 801-792-7335