Basic Information
| Provider Information | |||||||||
| NPI: | 1083879928 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | HEIDI | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 668 | ||||||||
| Address2: | |||||||||
| City: | ARVADA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800010668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034229438 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8300 W 38TH AVE | ||||||||
| Address2: | |||||||||
| City: | WHEAT RIDGE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800336005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034229438 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2008 | ||||||||
| LastUpdateDate: | 05/02/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 41080 | WI | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | MD166703 | OR | N | Allopathic & Osteopathic Physicians | Anesthesiology | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207L00000X | 50958 | CO | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 500676017 | 05 | OR | MEDICAID | 63356236 | 05 | CO | MEDICAID |