Provider Demographics
NPI:1952411688
Name:GREEN, MICHAEL
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
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:CMR 415 BOX 3677
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09114
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:GRAFENWOEHR HC
Practice Address - Street 2:CMR 415
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09114
Practice Address - Country:US
Practice Address - Phone:01149964-183-7152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXB1586924146N00000X
NY051907A235500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
Not Answered235500000XSpeech, Language and Hearing Service ProvidersSpecialist/Technologist