Basic Information
| Provider Information | |||||||||
| NPI: | 1619919552 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | HERBERT | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 GRAND STREET | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | WARWICK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109901035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8458563284 | ||||||||
| FaxNumber: | 8459875979 | ||||||||
| Practice Location | |||||||||
| Address1: | 161 E MAIN ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | PORT JERVIS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 127712113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8458563284 | ||||||||
| FaxNumber: | 8458563306 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 11/19/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD438011 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 143931 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01723019 | 05 | NY | MEDICAID |