Provider Demographics
NPI:1619919552
Name:GREEN, HERBERT M (MD)
Entity Type:Individual
Prefix:
First Name:HERBERT
Middle Name:M
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:20 GRAND STREET
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:WARWICK
Mailing Address - State:NY
Mailing Address - Zip Code:10990-1035
Mailing Address - Country:US
Mailing Address - Phone:845-856-3284
Mailing Address - Fax:845-987-5979
Practice Address - Street 1:161 E MAIN ST
Practice Address - Street 2:SUITE 300
Practice Address - City:PORT JERVIS
Practice Address - State:NY
Practice Address - Zip Code:12771-2113
Practice Address - Country:US
Practice Address - Phone:845-856-3284
Practice Address - Fax:845-856-3306
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2018-11-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PAMD438011207R00000X
NY143931207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01723019Medicaid
NY01723019Medicaid
NYG66783Medicare UPIN