Provider Demographics
NPI:1033156112
Name:GREEN, BARRY LEE (DO)
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:LEE
Last Name:GREEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 MORGAN HWY
Mailing Address - Street 2:WOMEN'S CARE CENTER
Mailing Address - City:CLARKS SUMMIT
Mailing Address - State:PA
Mailing Address - Zip Code:18411-9139
Mailing Address - Country:US
Mailing Address - Phone:570-586-6637
Mailing Address - Fax:570-587-0547
Practice Address - Street 1:407 N STATE ST
Practice Address - Street 2:
Practice Address - City:CLARKS SUMMIT
Practice Address - State:PA
Practice Address - Zip Code:18411-1097
Practice Address - Country:US
Practice Address - Phone:570-586-6637
Practice Address - Fax:570-587-0547
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS012339207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019596100006Medicaid
PA070918YGDBMedicare PIN
H87464Medicare UPIN