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General NPI Number Information
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NPI Number | 1245566348
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Entity Type | Organization
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Legal Business Name | KITSAP COLORECTAL SURGERY INC PS
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Dates
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Enumeration Date | 10/23/2009
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Last Update Date | 10/23/2009
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Provider Practice Location Address
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Address Line | 2528 WHEATON WAY SUITE 103
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City | BREMERTON
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State | WA
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Zip | 98310-3305
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Country | US
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Telephone | 360-377-4717
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Fax | 360-377-4134
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Provider Business Mailing Address
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Address Line | 2528 WHEATON WAY SUITE 103
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City | BREMERTON
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State | WA
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Zip | 98310-3305
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Country | US
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Telephone | 360-377-4717
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Fax | 360-377-4134
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JOHNNY B GREEN
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Credential | MD
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Telephone | 360-377-4717
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208C00000X
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Taxonomy Name | Colon & Rectal Surgery Physician
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License Number | 35113
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 35113
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License Number State | WA
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