Provider Demographics
NPI:1336475219
Name:GREEN, MATTHEW ROBERT (PA-C)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ROBERT
Last Name:GREEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 NORTH AVE
Mailing Address - Street 2:CBO-
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49017-0000
Mailing Address - Country:US
Mailing Address - Phone:269-245-8230
Mailing Address - Fax:269-245-8251
Practice Address - Street 1:5352 BECKLEY RD
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49015-4155
Practice Address - Country:US
Practice Address - Phone:269-965-4500
Practice Address - Fax:269-965-1150
Is Sole Proprietor?:No
Enumeration Date:2009-10-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006130363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1104840529OtherBCBS - BRONSON
MI1336475219Medicaid
MI1336475219Medicaid