Provider Demographics
NPI:1912973595
Name:GREEN, MICHAEL R (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:R
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 1:98 15TH ST NW STE 207A
Mailing Address - Street 2:
Mailing Address - City:NORTON
Mailing Address - State:VA
Mailing Address - Zip Code:24273-1600
Mailing Address - Country:US
Mailing Address - Phone:276-439-1490
Mailing Address - Fax:276-439-1495
Practice Address - Street 1:98 15TH ST NW STE 207A
Practice Address - Street 2:
Practice Address - City:NORTON
Practice Address - State:VA
Practice Address - Zip Code:24273-1600
Practice Address - Country:US
Practice Address - Phone:276-439-1490
Practice Address - Fax:276-439-1495
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101256059207R00000X, 207RS0012X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1861674160Medicaid
VAP01487168OtherRAILROAD MEDICARE
KY7100409190Medicaid
VA1912973595Medicaid
VAP01487168OtherRAILROAD MEDICARE
VA1912973595Medicaid
KSA62398Medicare UPIN
PAP00734669Medicare PIN
MD956320OtherCAREFIRST MD BCBS-WMG
PA094841FLTMedicare PIN
PA1557742OtherGATEWAY-WMG
KSA62398Medicare UPIN
PAP00734669Medicare PIN