MEDICARE: RONALD W GREEN JR. PA

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	174400000X	Specialist	213	WV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	001720686	OTHER	WV	BLUE CROSS
2	2103752	OTHER	WV	MAMSI

General Provider Information

NPI Number	:	1366432601
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RONALD W GREEN JR. PA

Provider Business Mailing Address
First Line	:	PO BOX 550
Second Line	:
City	:	BEAVER
State	:	WV
Zip	:	25813-0550
Country	:	US
Telephone Number	:	304-255-1300
Fax Number	:	304-255-5391

Provider Business Practice Location Address
First Line	:	703 RITTER DRIVE
Second Line	:
City	:	BEAVER
State	:	WV
Zip	:	25813
Country	:	US
Telephone Number	:	304-255-1300
Fax Number	:	304-255-5391

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

Provider Enumeration Date	:	10/27/2005
Last Update Date	:	07/08/2007

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