Provider Demographics
NPI:1083610752
Name:GREEN, PHIL JAMES (PAC)
Entity Type:Individual
Prefix:
First Name:PHIL
Middle Name:JAMES
Last Name:GREEN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 W FERGUSON AVE
Mailing Address - Street 2:
Mailing Address - City:BLACKWELL
Mailing Address - State:OK
Mailing Address - Zip Code:74631-5602
Mailing Address - Country:US
Mailing Address - Phone:580-363-0052
Mailing Address - Fax:580-363-0894
Practice Address - Street 1:1009 W FERGUSON AVE
Practice Address - Street 2:
Practice Address - City:BLACKWELL
Practice Address - State:OK
Practice Address - Zip Code:74631-5602
Practice Address - Country:US
Practice Address - Phone:580-363-0052
Practice Address - Fax:580-363-0894
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA800207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
S61707Medicare UPIN