MEDICARE: SCOTT G 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	207N00000X	Dermatology Physician	24935	IA

General Provider Information

NPI Number	:	1760454821
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SCOTT G GREEN MD

Provider Business Mailing Address
First Line	:	22 N 27TH ST
Second Line	:
City	:	FORT DODGE
State	:	IA
Zip	:	50501-4331
Country	:	US
Telephone Number	:	515-955-4440
Fax Number	:

Provider Business Practice Location Address
First Line	:	22 N 27TH ST
Second Line	:
City	:	FORT DODGE
State	:	IA
Zip	:	50501-4331
Country	:	US
Telephone Number	:	515-955-4440
Fax Number	:

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

Provider Enumeration Date	:	02/03/2006
Last Update Date	:	02/18/2015

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