Provider Demographics
NPI:1932106093
Name:GREEN, THOMAS W JR (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:W
Last Name:GREEN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37662-0009
Mailing Address - Country:US
Mailing Address - Phone:423-857-2066
Mailing Address - Fax:423-857-2070
Practice Address - Street 1:1 MEDICAL PARK BLVD
Practice Address - Street 2:STE 450W
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-7430
Practice Address - Country:US
Practice Address - Phone:423-968-3713
Practice Address - Fax:423-968-7352
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN009980207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VI6016910Medicaid
VA014531OtherANTHEM
TN3037795OtherBLUE CROSS
3104412Medicare ID - Type Unspecified
VI6016910Medicaid