Provider Demographics
NPI:1942286463
Name:GREEN, JOHN G (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:G
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 EASTERN SHORE DR
Mailing Address - Street 2:P.O. BOX 49
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-5565
Mailing Address - Country:US
Mailing Address - Phone:410-749-8906
Mailing Address - Fax:410-219-5662
Practice Address - Street 1:400 EASTERN SHORE DR
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-5565
Practice Address - Country:US
Practice Address - Phone:410-749-8906
Practice Address - Fax:410-219-5662
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD02020207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD29551500Medicaid
MDH6403812Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL
MD29551500Medicaid