Provider Demographics
NPI:1801086715
Name:GREEN MEDICAL CLINIC
Entity type:Organization
Organization Name:GREEN MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-456-8989
Mailing Address - Street 1:1 PLAZA SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-4750
Mailing Address - Country:US
Mailing Address - Phone:918-456-8989
Mailing Address - Fax:918-456-7989
Practice Address - Street 1:23507 EAST RIVERVIEW DRIVE
Practice Address - Street 2:
Practice Address - City:COOKSON
Practice Address - State:OK
Practice Address - Zip Code:74427
Practice Address - Country:US
Practice Address - Phone:918-456-8989
Practice Address - Fax:918-456-7989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-26
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK9260207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKD05217OtherUPIN
OK100093200DMedicaid
OKD05217OtherUPIN