Provider Demographics
NPI:1104022409
Name:JAMES M GREEN PS
Entity Type:Organization
Organization Name:JAMES M GREEN PS
Other - Org Name:BREMERTON PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:360-377-3395
Mailing Address - Street 1:900 SHERIDAN RD.
Mailing Address - Street 2:#109
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310-2701
Mailing Address - Country:US
Mailing Address - Phone:360-377-3395
Mailing Address - Fax:360-792-1249
Practice Address - Street 1:900 SHERIDAN RD.
Practice Address - Street 2:#109
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-2701
Practice Address - Country:US
Practice Address - Phone:360-377-3395
Practice Address - Fax:360-792-1249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-23
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00002393225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8141202Medicaid
WAWA7267008Medicaid
WA190150200OtherFEDERAL DEPT OF LABOR
WA0197563OtherSTATE L&I
WAG8854055Medicare PIN
WA8141202Medicaid