MEDICARE: TRACEY D GREEN 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	207Q00000X	Family Medicine Physician	7233	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1487631768	OTHER		NPI
2	11040458	OTHER		CAQH

General Provider Information

NPI Number	:	1487631768
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACEY D GREEN MD

Provider Business Mailing Address
First Line	:	2345 E PRATER WAY
Second Line	:	SUITE 104
City	:	SPARKS
State	:	NV
Zip	:	89434-9600
Country	:	US
Telephone Number	:	775-356-4547
Fax Number	:	775-356-4541

Provider Business Practice Location Address
First Line	:	2345 E PRATER WAY
Second Line	:	SUITE 207
City	:	SPARKS
State	:	NV
Zip	:	89434-9600
Country	:	US
Telephone Number	:	775-356-4547
Fax Number	:	775-356-4541

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

Provider Enumeration Date	:	12/28/2005
Last Update Date	:	07/05/2013

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