Provider Demographics
NPI:1861494718
Name:GREEN, THOMAS A (DC)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:A
Last Name:GREEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:FITZGERALD
Mailing Address - State:GA
Mailing Address - Zip Code:31750-2441
Mailing Address - Country:US
Mailing Address - Phone:229-423-2196
Mailing Address - Fax:
Practice Address - Street 1:321 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:FITZGERALD
Practice Address - State:GA
Practice Address - Zip Code:31750-2441
Practice Address - Country:US
Practice Address - Phone:229-423-2196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-11
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR004988111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000564154AMedicaid
GA350028505Medicare ID - Type UnspecifiedRAILROAD MEDICARE
GA35ZCCJBMedicare ID - Type Unspecified
GA000564154AMedicaid
GA52429367Medicare UPIN