Provider Demographics
NPI:1467400333
Name:GREEN, RANDALL WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:WILLIAM
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 1:4070 LAKE DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-8294
Mailing Address - Country:US
Mailing Address - Phone:616-774-8200
Mailing Address - Fax:616-774-0304
Practice Address - Street 1:4070 LAKE DR SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8294
Practice Address - Country:US
Practice Address - Phone:616-774-8200
Practice Address - Fax:616-774-0304
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRG030071174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI110158828OtherRAILROAD MEDICARE
MIRG030071OtherSTATE LICENSE NUMBER
MI1104110132OtherBLUE CROSS BLUE SHIELD
MI1073594Medicaid
MI1073594Medicaid
MI1104110132OtherBLUE CROSS BLUE SHIELD