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General NPI Number Information
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NPI Number | 1801086715
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Entity Type | Organization
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Legal Business Name | GREEN MEDICAL CLINIC
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Dates
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Enumeration Date | 07/26/2007
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Last Update Date | 11/01/2012
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Provider Practice Location Address
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Address Line | 23507 EAST RIVERVIEW DRIVE
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City | COOKSON
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State | OK
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Zip | 74427
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Country | US
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Telephone | 918-456-8989
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Fax | 918-456-7989
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Provider Business Mailing Address
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Address Line | 1 PLAZA SOUTH ST
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City | TAHLEQUAH
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State | OK
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Zip | 74464-4750
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Country | US
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Telephone | 918-456-8989
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Fax | 918-456-7989
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Authorized Official
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Title or Position | OWNER
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Name | DR. LAWRENCE CHARLES GREEN
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Credential | M.D.
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Telephone | 918-456-8989
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 9260
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License Number State | OK
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