Provider Demographics
NPI:1790929230
Name:GREEN, DANIEL R (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:R
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
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 743294
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3294
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:UPSTATE CARDIOLOGY
Practice Address - Street 2:2 INNOVATION DRIVE, STE 400
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-5270
Practice Address - Country:US
Practice Address - Phone:864-235-7665
Practice Address - Fax:864-233-5971
Is Sole Proprietor?:No
Enumeration Date:2009-04-28
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC51716207RI0011X
IN01076895A207R00000X, 207RI0011X
390200000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC517168Medicaid