Provider Demographics
NPI:1417178187
Name:GREEN, CLYDE O (MD)
Entity Type:Individual
Prefix:DR
First Name:CLYDE
Middle Name:O
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:841 MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-6756
Mailing Address - Country:US
Mailing Address - Phone:478-741-6554
Mailing Address - Fax:478-743-7052
Practice Address - Street 1:841 MULBERRY ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-6756
Practice Address - Country:US
Practice Address - Phone:478-741-6554
Practice Address - Fax:478-743-7052
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA30072207Q00000X, 207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA157763300OtherWORKER COMP
GA324341OtherWELLCARE
GA508457OtherBLUE CROSS BLUE SHIELD
GA157763302OtherWORKERS COMP
GA00358432 D, E, F, JMedicaid
GAD45482GRE00OtherSECURE CHOICE HEALTH
GA105116OtherPEACH STATE
GA1451889OtherUNITED HEALTH CARE
GA157763301OtherWORKERS COMP
GA324341OtherWELLCARE
GA157763301OtherWORKERS COMP
GA080083715Medicare ID - Type UnspecifiedRAILROAD