Basic Information
| Provider Information | |||||||||
| NPI: | 1922077692 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | ARCHIBALD | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GREEN | ||||||||
| OtherFirstName: | ARCHIE | ||||||||
| OtherMiddleName: | H | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4 GLEN COVE DR | ||||||||
| Address2: | STE 202 | ||||||||
| City: | ROCKPORT | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04856 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2075935800 | ||||||||
| FaxNumber: | 2075935322 | ||||||||
| Practice Location | |||||||||
| Address1: | 4 GLEN COVE DR | ||||||||
| Address2: | STE 202 | ||||||||
| City: | ROCKPORT | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04856 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2075935800 | ||||||||
| FaxNumber: | 2075935322 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2006 | ||||||||
| LastUpdateDate: | 12/28/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 1327 | ME | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 258360099 | 05 | ME | MEDICAID |