Provider Demographics
NPI:1922077692
Name:GREEN, ARCHIBALD H (DO)
Entity Type:Individual
Prefix:
First Name:ARCHIBALD
Middle Name:H
Last Name:GREEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:ARCHIE
Other - Middle Name:H
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:4 GLEN COVE DR
Mailing Address - Street 2:STE 202
Mailing Address - City:ROCKPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04856
Mailing Address - Country:US
Mailing Address - Phone:207-593-5800
Mailing Address - Fax:207-593-5322
Practice Address - Street 1:4 GLEN COVE DR
Practice Address - Street 2:STE 202
Practice Address - City:ROCKPORT
Practice Address - State:ME
Practice Address - Zip Code:04856
Practice Address - Country:US
Practice Address - Phone:207-593-5800
Practice Address - Fax:207-593-5322
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1327207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME258360099Medicaid
ME258360099Medicaid
MM3035Medicare ID - Type Unspecified