Provider Demographics
NPI:1417541731
Name:GREEN, ANDREW TYLER
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:TYLER
Last Name:GREEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 GERVAIS RD
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN FURNACE
Mailing Address - State:OH
Mailing Address - Zip Code:45629-8742
Mailing Address - Country:US
Mailing Address - Phone:740-259-7000
Mailing Address - Fax:740-259-7003
Practice Address - Street 1:303 GERVAIS RD
Practice Address - Street 2:
Practice Address - City:FRANKLIN FURNACE
Practice Address - State:OH
Practice Address - Zip Code:45629-8742
Practice Address - Country:US
Practice Address - Phone:740-259-7000
Practice Address - Fax:740-259-7003
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-26
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty