Provider Demographics
NPI:1710106588
Name:GREEN, THOMAS FITZGERALD (CCVT)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:FITZGERALD
Last Name:GREEN
Suffix:
Gender:M
Credentials:CCVT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 MEMORIAL DR
Mailing Address - Street 2:11F
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-3235
Mailing Address - Country:US
Mailing Address - Phone:404-210-8912
Mailing Address - Fax:
Practice Address - Street 1:1670 CLAIRMONT RD
Practice Address - Street 2:DEPT OF CARDIOLOGY
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-4004
Practice Address - Country:US
Practice Address - Phone:404-321-6111
Practice Address - Fax:404-329-2211
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA246XC2901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246XC2901XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist CardiovascularCardiovascular Invasive Specialist