Provider Demographics
NPI:1447359054
Name:GREEN, MICHAEL D (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:D
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 KENWOOD ST
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-5118
Mailing Address - Country:US
Mailing Address - Phone:201-602-4444
Mailing Address - Fax:
Practice Address - Street 1:380 KENWOOD ST
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-5118
Practice Address - Country:US
Practice Address - Phone:201-602-4444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2025-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA037950002085R0202X
NY120848-12085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY55197BMedicare PIN
NYD96968Medicare UPIN
NYRA0369Medicare PIN
NYCC0828Medicare PIN