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General NPI Number Information
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NPI Number | 1891004420
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Entity Type | Organization
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Legal Business Name | PETER GREEN MD PA
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Dates
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Enumeration Date | 09/30/2010
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Last Update Date | 09/30/2010
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Provider Practice Location Address
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Address Line | 11801 SOUTH FWY SUITE 234
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City | BURLESON
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State | TX
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Zip | 76028-7021
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Country | US
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Telephone | 817-293-2944
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Fax | 817-293-2039
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Provider Business Mailing Address
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Address Line | PO BOX 6337
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City | FORT WORTH
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State | TX
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Zip | 76115-0337
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Country | US
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Telephone | 817-293-2944
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Fax | 817-293-2039
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Authorized Official
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Title or Position | MD
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Name | DR. PETER GREEN
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Credential | MD
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Telephone | 817-293-2944
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | F8497
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License Number State | TX
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