MEDICARE: JUSTIN D 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	208100000X	Physical Medicine & Rehabilitation Physician	32177	CO

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	:	1841355971
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUSTIN D GREEN M.D.

Provider Business Mailing Address
First Line	:	PO BOX 1588
Second Line	:
City	:	BOULDER
State	:	CO
Zip	:	80306-1588
Country	:	US
Telephone Number	:	303-442-5492
Fax Number	:

Provider Business Practice Location Address
First Line	:	5277 MANHATTAN CIR
Second Line	:	SUITE 100
City	:	BOULDER
State	:	CO
Zip	:	80303-8201
Country	:	US
Telephone Number	:	720-304-8154
Fax Number	:

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

Provider Enumeration Date	:	12/27/2006
Last Update Date	:	07/08/2007

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