Provider Demographics
NPI:1851893234
Name:GREEN, BOBBY DURELL
Entity Type:Individual
Prefix:
First Name:BOBBY
Middle Name:DURELL
Last Name:GREEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 MURRAY ST APT 9
Mailing Address - Street 2:
Mailing Address - City:COVENTRY
Mailing Address - State:RI
Mailing Address - Zip Code:02816-8122
Mailing Address - Country:US
Mailing Address - Phone:401-677-9595
Mailing Address - Fax:
Practice Address - Street 1:50 MURRAY ST APT 9
Practice Address - Street 2:
Practice Address - City:COVENTRY
Practice Address - State:RI
Practice Address - Zip Code:02816-8122
Practice Address - Country:US
Practice Address - Phone:401-677-9595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-01
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program