Provider Demographics
NPI:1508249947
Name:RICHARD D. GREEN, MD, PC
Entity Type:Organization
Organization Name:RICHARD D. GREEN, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:DEWAR
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-577-4280
Mailing Address - Street 1:940 E 3RD ST STE 102
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-3200
Mailing Address - Country:US
Mailing Address - Phone:307-577-4280
Mailing Address - Fax:307-577-4283
Practice Address - Street 1:940 E 3RD ST STE 102
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-3200
Practice Address - Country:US
Practice Address - Phone:307-577-4280
Practice Address - Fax:307-577-4283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-02
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY2373A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY106467300Medicaid