Basic Information
| Provider Information | |||||||||
| NPI: | 1366431025 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | VINCENT | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 E MCBEE AVE FL 4 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296012842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645222286 | ||||||||
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| Practice Location | |||||||||
| Address1: | 106 PARKVIEW DR | ||||||||
| Address2: | |||||||||
| City: | LAURENS | ||||||||
| State: | SC | ||||||||
| PostalCode: | 293602652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8649840571 | ||||||||
| FaxNumber: | 8649843610 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2005 | ||||||||
| LastUpdateDate: | 05/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 31396 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 313967 | 05 | SC | MEDICAID | 7523807 | 05 | NJ | MEDICAID |