Provider Demographics
NPI:1780673525
Name:GREEN, GREGORY G (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:G
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 1:376 APPLE AVE
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49442-3466
Mailing Address - Country:US
Mailing Address - Phone:231-724-1111
Mailing Address - Fax:231-720-3295
Practice Address - Street 1:376 APPLE AVE
Practice Address - Street 2:SUITE 307
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-3466
Practice Address - Country:US
Practice Address - Phone:231-724-1111
Practice Address - Fax:231-720-3295
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-14
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010740482084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0E361760Medicare ID - Type Unspecified
MII12097Medicare UPIN
MI104622330Medicaid