Provider Demographics
NPI:1689672057
Name:GREEN, THOMAS G (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:G
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:5008 BRITTONFIELD PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-9248
Mailing Address - Country:US
Mailing Address - Phone:315-234-7600
Mailing Address - Fax:
Practice Address - Street 1:736 IRVING AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1687
Practice Address - Country:US
Practice Address - Phone:315-470-7551
Practice Address - Fax:315-470-2719
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2012-08-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY2135902085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G95845Medicare UPIN