Provider Demographics
NPI:1912188715
Name:GREEN MOUNTAIN MEDICAL CLINIC PC
Entity Type:Organization
Organization Name:GREEN MOUNTAIN MEDICAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WARREN
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:GRIFFITH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:541-782-4201
Mailing Address - Street 1:48260 HILLS ST
Mailing Address - Street 2:
Mailing Address - City:OAKRIDGE
Mailing Address - State:OR
Mailing Address - Zip Code:97463-9409
Mailing Address - Country:US
Mailing Address - Phone:541-782-4201
Mailing Address - Fax:541-782-4203
Practice Address - Street 1:48260 HILLS ST
Practice Address - Street 2:
Practice Address - City:OAKRIDGE
Practice Address - State:OR
Practice Address - Zip Code:97463-9409
Practice Address - Country:US
Practice Address - Phone:541-782-4201
Practice Address - Fax:541-782-4203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-20
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO10127261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR231498Medicaid
ORR0000LGBFTMedicare PIN
ORF00157Medicare UPIN