Basic Information
| Provider Information | |||||||||
| NPI: | 1386850634 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | MILTON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15214 CANYON RD E STE 120 | ||||||||
| Address2: | |||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983757472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535394200 | ||||||||
| FaxNumber: | 2535396025 | ||||||||
| Practice Location | |||||||||
| Address1: | 15214 CANYON RD E STE 120 | ||||||||
| Address2: | |||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983757472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535394200 | ||||||||
| FaxNumber: | 2535396025 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2007 | ||||||||
| LastUpdateDate: | 04/26/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD00047282 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4286GR | 01 | WA | BLUE SHIELD# | OTHER | 8490633 | 05 | WA | MEDICAID | 0264326 | 01 | WA | STATE L&I | OTHER | 0039581 | 01 | WA | LABOR AND INDUSTRIES # | OTHER | 0264328 | 01 | WA | STATE L&I | OTHER |