Provider Demographics
NPI:1982625836
Name:BERT GREEN, M.D., P.S.
Entity Type:Organization
Organization Name:BERT GREEN, M.D., P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BERT
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:206-241-1818
Mailing Address - Street 1:16259 SYLVESTER RD SW
Mailing Address - Street 2:SUITE 404
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98166-3049
Mailing Address - Country:US
Mailing Address - Phone:206-592-5000
Mailing Address - Fax:206-824-9510
Practice Address - Street 1:16259 SYLVESTER RD SW
Practice Address - Street 2:SUITE 404
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166-3049
Practice Address - Country:US
Practice Address - Phone:206-241-1818
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1890003Medicaid
WA060036294OtherRR MEDICARE
WA060036294OtherRR MEDICARE
WAG000101925Medicare PIN