MEDICARE: DR. WAVERLY SYNDOR GREEN III MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RP1001X	Pulmonary Disease Physician	9300133	NC
2	207RP1001X	Pulmonary Disease Physician	15701	NH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	29211	OTHER	NC	BCBS-IND.
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1235123191
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WAVERLY SYNDOR GREEN III MD

Provider Business Mailing Address
First Line	:	580 SAINT JOHNSBURY RD
Second Line	:	SUITE 25
City	:	LITTLETON
State	:	NH
Zip	:	03561-3437
Country	:	US
Telephone Number	:	603-259-7780
Fax Number	:	603-444-2769

Provider Business Practice Location Address
First Line	:	580 SAINT JOHNSBURY RD
Second Line	:	SUITE 25
City	:	LITTLETON
State	:	NH
Zip	:	03561-3437
Country	:	US
Telephone Number	:	603-259-7780
Fax Number	:	603-444-2769

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/07/2005
Last Update Date	:	09/24/2012

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