Provider Demographics
NPI:1295791366
Name:GREEN, BRYAN ROBERT (MD)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:ROBERT
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 1:2016 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64468-2655
Mailing Address - Country:US
Mailing Address - Phone:660-562-2525
Mailing Address - Fax:660-562-7996
Practice Address - Street 1:2016 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:MO
Practice Address - Zip Code:64468-2655
Practice Address - Country:US
Practice Address - Phone:660-562-7999
Practice Address - Fax:660-562-7996
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005034471207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1295791366OtherTRICARE
MO1295791366Medicaid
KS201084370AMedicaid
IA1295791366Medicaid
MO49561031OtherBCBSKC
MOP00273140OtherRR MEDICARE
IA1295791366Medicaid
MO49561031OtherBCBSKC