=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114299740
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BENJAMIN GREEN MD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2012
-----------------------------------------------------
Last Update Date | 01/27/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9245 LAGUNA SPRINGS DR SUITE 200
-----------------------------------------------------
City | ELK GROVE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95758-7987
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-624-6050
-----------------------------------------------------
Fax | 206-838-3085
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1525 4TH AVE SUITE 300
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98101-1607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-838-6856
-----------------------------------------------------
Fax | 206-838-3085
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | BENJAMIN MICHAEL GREEN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 206-914-2389
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------