MEDICARE: NATHAN GREEN LISW

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	104100000X	Social Worker	I8029	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000376633	OTHER	OH	ANTHEM BCBS

General Provider Information

NPI Number	:	1841387362
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NATHAN GREEN LISW

Provider Business Mailing Address
First Line	:	1943 NEWARK GRANVILLE RD
Second Line	:
City	:	GRANVILLE
State	:	OH
Zip	:	43023-9169
Country	:	US
Telephone Number	:	740-587-5252
Fax Number	:	740-587-2571

Provider Business Practice Location Address
First Line	:	1943 NEWARK GRANVILLE RD
Second Line	:
City	:	GRANVILLE
State	:	OH
Zip	:	43023-9169
Country	:	US
Telephone Number	:	740-587-5252
Fax Number	:	740-587-2571

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

Provider Enumeration Date	:	10/06/2006
Last Update Date	:	07/08/2007

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