Provider Demographics
NPI:1700886942
Name:GREEN, CHAD E
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:E
Last Name:GREEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6048 ROUTE 30
Mailing Address - Street 2:
Mailing Address - City:GREENSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15601-1279
Mailing Address - Country:US
Mailing Address - Phone:724-836-0802
Mailing Address - Fax:724-836-1190
Practice Address - Street 1:6048 ROUTE 30
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:PA
Practice Address - Zip Code:15601-1279
Practice Address - Country:US
Practice Address - Phone:724-836-0802
Practice Address - Fax:724-836-1190
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000086152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017553980001Medicaid
PAU68418Medicare UPIN
PA901285XQ7Medicare PIN