Basic Information
| Provider Information | |||||||||
| NPI: | 1063665719 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | MATTHEW | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 81 N MARIO CAPECCHI DR | ||||||||
| Address2: | DEPARTMENT OF PEDIATRICS | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841131125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012137737 | ||||||||
| FaxNumber: | 8015877539 | ||||||||
| Practice Location | |||||||||
| Address1: | 81 N MARIO CAPECCHI DR | ||||||||
| Address2: | DEPARTMENT OF PEDIATRICS | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841131125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012137737 | ||||||||
| FaxNumber: | 8015877539 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2008 | ||||||||
| LastUpdateDate: | 12/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | BP10031712 | TX | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 2081P0010X | 2011017820 | MO | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pediatric Rehabilitation Medicine | 2081P0301X | 8728465-1204 | UT | N | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2081P0010X | 8728465-1204 | UT | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pediatric Rehabilitation Medicine |
No ID Information.