Healthcare Provider Details

I. General information

NPI: 1780711945
Provider Name (Legal Business Name): GORDON JAMES GREEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 PENNSYLVANIA AVE
CHARLESTON WV
25302-3351
US

IV. Provider business mailing address

1416 VIRGINIA ST E
CHARLESTON WV
25301-3014
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-2525
  • Fax:
Mailing address:
  • Phone: 304-345-2766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number19355
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: