Provider Demographics
NPI:1477870749
Name:GREEN, ROLAND H JR (MD)
Entity Type:Individual
Prefix:DR
First Name:ROLAND
Middle Name:H
Last Name:GREEN
Suffix:JR
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 1:1120 15TH ST
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30912-0004
Mailing Address - Country:US
Mailing Address - Phone:706-721-3813
Mailing Address - Fax:
Practice Address - Street 1:447 N BELAIR RD
Practice Address - Street 2:STE 104
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3091
Practice Address - Country:US
Practice Address - Phone:678-386-6201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-27
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD19400207R00000X
IN01089378A207R00000X
PAMD463717207R00000X
MI4301114090207R00000X
CAC159465207R00000X
ORMD190366207R00000X
CODR.0062519207R00000X
FLME138295207R00000X
TXR8749207R00000X
GA071739207R00000X, 208D00000X
NY296123-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1477870749Medicare PIN