Provider Demographics
NPI:1508855925
Name:GREEN, BERT (MD)
Entity Type:Individual
Prefix:
First Name:BERT
Middle Name:
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 1:16259 SYLVESTER RD SW
Mailing Address - Street 2:SUITE 404
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98166-3049
Mailing Address - Country:US
Mailing Address - Phone:206-248-0800
Mailing Address - Fax:
Practice Address - Street 1:16259 SYLVESTER RD SW
Practice Address - Street 2:STE 404
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166-3049
Practice Address - Country:US
Practice Address - Phone:206-248-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00016483207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA060036294OtherRR MEDICARE
WA1890003Medicaid
WAG000101925Medicare PIN
WA1890003Medicaid