Provider Demographics
NPI:1316416860
Name:GREEN, RAYMOND B (RPT)
Entity Type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:B
Last Name:GREEN
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1575 ELM ST NE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-3715
Mailing Address - Country:US
Mailing Address - Phone:770-864-8806
Mailing Address - Fax:
Practice Address - Street 1:1575 ELM ST NE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-3715
Practice Address - Country:US
Practice Address - Phone:770-864-8806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-14
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12946819246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1316416860Medicaid