Provider Demographics
NPI:1134182769
Name:GREEN, ROBERT (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
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 1:720 HARRISON AVE
Mailing Address - Street 2:SUITE 707
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2371
Mailing Address - Country:US
Mailing Address - Phone:617-638-8456
Mailing Address - Fax:617-638-8465
Practice Address - Street 1:720 HARRISON AVE
Practice Address - Street 2:SUITE 707
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2371
Practice Address - Country:US
Practice Address - Phone:617-638-8456
Practice Address - Fax:617-638-8465
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA497902084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3199916Medicaid
MAD45479Medicare UPIN
MAAZ99973Medicare ID - Type Unspecified