Provider Demographics
NPI:1528015591
Name:GREEN, JOHN CHARLES (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CHARLES
Last Name:GREEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:6481 CARLISLE PIKE
Mailing Address - Street 2:
Mailing Address - City:MECHANICSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17050-2377
Mailing Address - Country:US
Mailing Address - Phone:717-516-6396
Mailing Address - Fax:717-620-8093
Practice Address - Street 1:6481 CARLISLE PIKE
Practice Address - Street 2:
Practice Address - City:MECHANICSBURG
Practice Address - State:PA
Practice Address - Zip Code:17050-2377
Practice Address - Country:US
Practice Address - Phone:717-516-6396
Practice Address - Fax:717-620-8093
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH34 00 52102083S0010X
PAOS 005621 L208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001007392Medicaid
1528015591OtherNPI
OH2055449OtherMOLINA MEDICAID
OH0125294000Medicaid
P00284946OtherRR MEDICARE
OH310917085084OtherCARESOURCE MEDICAID
OH000000181658OtherUNISON MEDICAID
P00284946OtherRR MEDICARE
PA172850Medicare PIN
OHC32742Medicare UPIN
OH0125294000Medicaid
PAP01536950Medicare PIN