Provider Demographics
NPI:1023147683
Name:ROGER GREEN, M.D., PLLC
Entity type:Organization
Organization Name:ROGER GREEN, M.D., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:D
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-464-9999
Mailing Address - Street 1:10 EVERGREEN LN
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:NY
Mailing Address - Zip Code:12498-1621
Mailing Address - Country:US
Mailing Address - Phone:518-464-9999
Mailing Address - Fax:518-464-9650
Practice Address - Street 1:PINE WEST PLAZA, BLDG. #1
Practice Address - Street 2:WASHINGTON AVENUE EXTENSION
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205
Practice Address - Country:US
Practice Address - Phone:518-464-9999
Practice Address - Fax:518-464-9650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1794772080S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080S0012XAllopathic & Osteopathic PhysiciansPediatricsSleep MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01258988Medicaid