MEDICARE: CHARLES BRUCE GREEN M.D.

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	207Q00000X	Family Medicine Physician	G48009	CA

General Provider Information

NPI Number	:	1336262559
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES BRUCE GREEN M.D.

Provider Business Mailing Address
First Line	:	84 WESTOVER AVE SW
Second Line	:
City	:	BOLLING AFB
State	:	DC
Zip	:	20032-7432
Country	:	US
Telephone Number	:	210-862-7592
Fax Number	:	202-404-7084

Provider Business Practice Location Address
First Line	:	HQ USAF SG
Second Line	:	1780 AIR FORCE PENTAGON
City	:	WASHINGTON
State	:	DC
Zip	:	20330-0001
Country	:	US
Telephone Number	:	202-767-4766
Fax Number	:	202-404-7084

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

Provider Enumeration Date	:	04/10/2007
Last Update Date	:	07/08/2007

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