Provider Demographics
NPI:1023082054
Name:GREEN, CHARLES E (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:E
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 1:48 TUNNEL RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:POTTSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17901-3875
Mailing Address - Country:US
Mailing Address - Phone:570-622-5555
Mailing Address - Fax:570-622-2160
Practice Address - Street 1:48 TUNNEL RD
Practice Address - Street 2:SUITE 104
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-3875
Practice Address - Country:US
Practice Address - Phone:570-622-5555
Practice Address - Fax:570-622-2160
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD023441E207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAC28858Medicare UPIN
PA68493DX8Medicare ID - Type Unspecified