Provider Demographics
NPI:1154313674
Name:GREEN, CANDACE C (MD)
Entity Type:Individual
Prefix:DR
First Name:CANDACE
Middle Name:C
Last Name:GREEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CANDACE
Other - Middle Name:C
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2630 N COLUMBIA CENTER BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-4853
Mailing Address - Country:US
Mailing Address - Phone:509-420-5053
Mailing Address - Fax:509-492-5537
Practice Address - Street 1:2630 N COLUMBIA CENTER BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-4853
Practice Address - Country:US
Practice Address - Phone:509-420-5053
Practice Address - Fax:509-492-5537
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301073070207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0700410OtherPHP
MI1605910202OtherBCBS
MI4706065Medicaid
MI4709343Medicaid
MI4706056Medicaid
MIH49612Medicare UPIN
MIH49612Medicare UPIN