Provider Demographics
NPI:1144377300
Name:SCOTT M GREEN MD P C
Entity Type:Organization
Organization Name:SCOTT M GREEN MD P C
Other - Org Name:ACADEMY PARK FAMILY PRACTICE, PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:M
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-979-1559
Mailing Address - Street 1:7373 W JEFFERSON AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80235-2038
Mailing Address - Country:US
Mailing Address - Phone:303-979-1559
Mailing Address - Fax:303-986-6895
Practice Address - Street 1:7373 W JEFFERSON AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80235-2038
Practice Address - Country:US
Practice Address - Phone:303-979-1559
Practice Address - Fax:303-986-6895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO29123207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1801877519Medicaid
COC36231Medicare ID - Type UnspecifiedMEDICARE
COD03131Medicare UPIN