Provider Demographics
NPI:1083647788
Name:ANDY GREEN MD PA
Entity Type:Organization
Organization Name:ANDY GREEN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDY
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PA
Authorized Official - Phone:305-945-2877
Mailing Address - Street 1:1380 NE MIAMI GARDENS DR
Mailing Address - Street 2:STE 270
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33179-4721
Mailing Address - Country:US
Mailing Address - Phone:305-945-2877
Mailing Address - Fax:305-945-2878
Practice Address - Street 1:1380 NE MIAMI GARDENS DR
Practice Address - Street 2:STE 270
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33179-4721
Practice Address - Country:US
Practice Address - Phone:305-945-2877
Practice Address - Fax:305-945-2878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2007-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME86150207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK7488Medicare PIN
FL29163ZMedicare ID - Type Unspecified
FLH92491Medicare UPIN