Provider Demographics
NPI:1417079062
Name:JOHN N GREEN, M.D.,PA
Entity Type:Organization
Organization Name:JOHN N GREEN, M.D.,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:NEZZEL
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-669-1111
Mailing Address - Street 1:61 MAIN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-5311
Mailing Address - Country:US
Mailing Address - Phone:973-669-1111
Mailing Address - Fax:973-669-3535
Practice Address - Street 1:61 MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-5311
Practice Address - Country:US
Practice Address - Phone:973-669-1111
Practice Address - Fax:973-669-3535
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JOHN N GREEN, M.D.,PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-04
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA40057207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ512575V86Medicare ID - Type UnspecifiedRENDERING PROV ID
NJD19241Medicare UPIN
NJ108556Medicare ID - Type UnspecifiedGROUP PROVIDER ID