Provider Demographics
NPI:1114909512
Name:GREEN, KENNETH R (MD)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:R
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 BUCKLEY ROAD
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212
Mailing Address - Country:US
Mailing Address - Phone:315-478-3311
Mailing Address - Fax:315-426-0796
Practice Address - Street 1:1304 BUCKLEY RD
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13212-4302
Practice Address - Country:US
Practice Address - Phone:315-478-3311
Practice Address - Fax:315-426-0796
Is Sole Proprietor?:No
Enumeration Date:2005-11-19
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY130245207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
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NY03260OtherEXCELLUS
NY00040696502OtherUNIVERA SENIOR CHOICE
NY4535679OtherAETNA
NY51136NMedicare Oscar/Certification
NY00914917001OtherHEALTHNOW
NYB81067Medicare UPIN