Provider Demographics
NPI:1790050698
Name:MARY KELLY GREEN MD PLLC
Entity Type:Organization
Organization Name:MARY KELLY GREEN MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:K
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-693-3787
Mailing Address - Street 1:204 GATEWAY N
Mailing Address - Street 2:SUITE C
Mailing Address - City:MARBLE FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:78654-6361
Mailing Address - Country:US
Mailing Address - Phone:803-693-3787
Mailing Address - Fax:803-798-8012
Practice Address - Street 1:204 GATEWAY N
Practice Address - Street 2:SUITE C
Practice Address - City:MARBLE FALLS
Practice Address - State:TX
Practice Address - Zip Code:78654-6361
Practice Address - Country:US
Practice Address - Phone:803-693-3787
Practice Address - Fax:803-798-8012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-12
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA6683960001Medicare NSC