Provider Demographics
NPI:1053385716
Name:GREEN, BRUCE G (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:G
Last Name:GREEN
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Gender:M
Credentials:MD
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Mailing Address - Street 1:5673 PEACHTREE DUNWOODY RD NE
Mailing Address - Street 2:STE 910
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1731
Mailing Address - Country:US
Mailing Address - Phone:404-255-3822
Mailing Address - Fax:404-255-0495
Practice Address - Street 1:5673 PEACHTREE DUNWOODY RD NE
Practice Address - Street 2:STE 910
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1731
Practice Address - Country:US
Practice Address - Phone:404-255-3822
Practice Address - Fax:404-255-0495
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2020-08-31
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Provider Licenses
StateLicense IDTaxonomies
GA016803208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D40009Medicare UPIN