Provider Demographics
NPI:1053755082
Name:GREEN PODIATRY LLC
Entity type:Organization
Organization Name:GREEN PODIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:609-217-8905
Mailing Address - Street 1:111 MAPLE GROVE BLVD
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08048-4617
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 MAPLE GROVE BLVD
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NJ
Practice Address - Zip Code:08048-4617
Practice Address - Country:US
Practice Address - Phone:609-217-8905
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-21
Last Update Date:2013-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00214300213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1094025OtherUNITED HEALTHCARE
NJ5486904Medicaid
P3800567OtherOXFORD
1725652OtherCIGNA
1725652OtherCIGNA
NJU33493Medicare UPIN