Provider Demographics
NPI:1659467223
Name:GREEN, RONA RENELL (DPM)
Entity Type:Individual
Prefix:DR
First Name:RONA
Middle Name:RENELL
Last Name:GREEN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 188
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-0188
Mailing Address - Country:US
Mailing Address - Phone:770-964-2201
Mailing Address - Fax:770-306-9744
Practice Address - Street 1:67 W. CAMPBELLTON ST.
Practice Address - Street 2:
Practice Address - City:FAIRBURN
Practice Address - State:GA
Practice Address - Zip Code:30213
Practice Address - Country:US
Practice Address - Phone:770-964-2201
Practice Address - Fax:770-306-9744
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000697213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA25127OtherCOVENTRY GEORGIA
GA000558467AMedicaid
GA451998OtherBCBS GEORGIA
AL51510661OtherAL BLUE CROSS BLUE SHEILD
GA57106OtherTRICARE GEORGIA
GA2700177OtherUNITED HEALTH CARE GA
GA4355747OtherAETNA GEORGIA
AL515129440OtherAL BCBS (ROANOKE OFFICE)
GA57106OtherTRICARE GEORGIA
AL631253539OtherAL TAX ID NUMBER
AL631253539OtherAL TAX ID NUMBER
GA2700177OtherUNITED HEALTH CARE GA
GAU52000Medicare UPIN
GA0912050001Medicare NSC
AL51510661OtherAL BLUE CROSS BLUE SHEILD
ALJ769Medicare PIN