Provider Demographics
NPI:1821093030
Name:GREEN, THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
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 1:305 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:KY
Mailing Address - Zip Code:42071-2404
Mailing Address - Country:US
Mailing Address - Phone:270-753-9300
Mailing Address - Fax:270-753-3549
Practice Address - Street 1:305 S 8TH ST
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:KY
Practice Address - Zip Code:42071-2404
Practice Address - Country:US
Practice Address - Phone:270-753-9300
Practice Address - Fax:270-753-3549
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY17975207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000308977OtherANTHEM
KY65940330Medicaid
KY65940330Medicaid
KY000000308977OtherANTHEM