MEDICARE: MICHAEL GREEN THAIN OD

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	152W00000X	Optometrist	1089949934	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1356415434
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL GREEN THAIN OD

Provider Business Mailing Address
First Line	:	12964 HUNTER HOLLOW WAY
Second Line	:
City	:	DRAPER
State	:	UT
Zip	:	84020
Country	:	US
Telephone Number	:	801-572-0594
Fax Number	:

Provider Business Practice Location Address
First Line	:	6895 SO STATE
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84047
Country	:	US
Telephone Number	:	801-255-8525
Fax Number	:

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

Provider Enumeration Date	:	11/20/2006
Last Update Date	:	07/08/2007

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