Provider Demographics
NPI:1518256650
Name:PATRICK GREEN MD PLLC
Entity Type:Organization
Organization Name:PATRICK GREEN MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:N
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-828-5857
Mailing Address - Street 1:134 W 1180 N SUITE # 5
Mailing Address - Street 2:
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074
Mailing Address - Country:US
Mailing Address - Phone:435-248-0333
Mailing Address - Fax:435-248-0334
Practice Address - Street 1:134 W 1180 N SUITE # 5
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074
Practice Address - Country:US
Practice Address - Phone:435-248-0333
Practice Address - Fax:435-248-0334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-29
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care